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EMERGENCY SURGERY 



SLU SS 



THE LEATHER BOUND SERIES 

OF 

MEDICAL MANUALS 



HUGHES. Compend of the Practice of Medicine. Ninth 
Edition. By Daniel E. Hughes, M. D., late Chief Resident 
Physician, Philadelphia Hospital. Revised by Samuel Horton 
Brown, M. D., Assistant Dermatologist, Philadelphia Hospital. 
With Illustrations. 785 pages. Flexible Leather, Gilt Edges, 
Round Corners. $2.50 

KYLE. Manual of Diseases of the Ear, Nose and Throat. 
Second Edition. By John Johnson Kyle, B. S., M. D., Pro- 
fessor of Otology, Rhinology and Laryngology in the Univer- 
sity of Southern California; Member of the American Laryn- 
gological, Rhinological and Otological Society. With 169 Il- 
lustrations. Flexible Leather, Gilt Edges, Round Corners. 

$3.00 

SLUSS. Emergency Surgery. Third Edition. By John W. 
Sluss, A. M., M. D., Associate Professor of Surgery, Indiana 
University School of Medicine; Ex-Superintendent Indianapolis 
City Hospital; Surgeon to the Indianapolis City Hospital. 
With 685 Illustrations, xvii+ 828 pages, nmo. Flexible 
Leather, Gilt Edges, Round Corners. $4.00 

THAYER. Manual of Pathology. 131 Illustrations. General 
and Special. By A. E. Thayer, M. D., Professor of Pathology, 
University of Texas; formerly Assistant Instructor in Path- 
ology, Cornell Medical School. With 131 Illustrations. 711 
pages. i2mo. Flexible Leather, Gilt Edges, Round Corners. 

$2.50 

* * * Other Volumes in Preparation. 

P. BLAKISTON'S SON & CO. 

Publishers : : PHILADELPHIA 



EMERGENCY SURGERY 



BY 

JOHN W. SLUSS, A.M., M.D. 

ASSOCIATE PROFESSOR OF SURGERY, INDIANA UNIVERSITY SCHOOL 
OF MEDICINE; EX-SUPERINTENDENT INDIANAPOLIS CITY HOS- 
PITAL*. SURGEON TO THE CITY HOSPITAL 



THIRD EDITION, REVISED AND ENLARGED 

WITH 685 ILLUSTRATIONS 

SOME OF WHICH ARE PRINTED IN COLORS 



PHILADELPHIA 

P. BLAKISTON'S SON & CO, 

1012 WALNUT STREET 






\ 



Copyright, 1915, by P. Blakiston's Son & Co. 



4¥ 



$''■■ 
539 



THE. MAPLE. PRESS. YORK. PA 



SEP 20 1915 

7u\ / '• 



DEDICATION 

R. E. B. EVANS, TYP 

GENERAL PRACTITIONERS, IX MEMORY OF DAYS SPENT 

TOGETHER, THIS LITTLE WORK IS INSCRIBED 



PREFACE TO THE THIRD EDITION 



The present revision of this volume has adhered to the aim of 
iormer editions to present general principles concisely, and prac- 
.ical details amply — in short to make a book useful to the general 
|practitioner in the surgical phase of his daily routine. 

Each subject has been carefully revised. The text on Fractures 
has been greatly increased, consonant with the new interest to the 
profession generally which this subject has acquired in recent 
years. 

The chapter on Military Surgery has been entirely rewritten in 
conformity with the surgical experiences of this latest and greatest 
war. A number of illustrations borrowed from the British Journal 
of Surgery and other sources are included. 

The Technique of the emergency interventions will be found 
to coincide w T ith the best practice of the present time. Finally 
the hope is expressed that the volume will continue, as in the 
past, to find favor with the medical public. 

J. W. S. 



VI 1 



PREFACE TO SECOND EDITION 



The fact that the first edition of this book was sold out within onel 
year is particularly gratifying to the author because it indicates that 
the results of his effort to make a useful and practical book have met| 
with the approval of the profession. 

In preparing this second edition of the " Emergency Surgery " the| 
effort has been to profit by the suggestions and criticisms of the 
various reviewers of the first. It is hoped, in consequence, that its 
usefulness has been increased and that it will continue to find favor 
with its readers. 

A new chapter on the general technic of Laparotomy has been 
added; each subject has been carefully reviewed; and in many in- 
stances new matter incorporated. Thus, for example, Spinal Anes- 
thesia is described in detail and Subphrenic Abscess and Pericardi- 
otomy more fully considered. 

Dr. Helen Knabe has contributed some new illustrations, and 
the skiagrams are the work of Dr. Albert M. Cole, of Indianapolis, 
to whom thanks are due. 

J. w. s. 



Vlll 



PREFACE TO THE FIRST EDITION 



This is a Surgery for the general practitioner; written not to 
nstruct his leisure hour, but in the hope some time to serve as a 
[uide out of uncertainty in a time of stress. Its merits and demerits 
hould be reckoned from that point of view alone. If, occasionally, 
he form of expression seems dogmatic, it merely comports with the 
:onstant aim to be practical; certainly that aim has denied any place 
to theoretical discussions and has curtailed reference to the various 
riews of recognized authority. An absence of bibliography, it is 
loped, therefore, will not be' regarded as discourtesy to the many 
writers, teachers, and practitioners whose ideas have been so freely 
appropriated. 

Among the text-books more constantly consulted are Senn's 
ractical Surgery, The American Text-book of Surgery, Walsham's 
Surgery, Treves' Operative Surgery, Lejars' Chirurgie d'Urgence, 
Veau's Chirurgie d'Urgence et Pratique Courante, Von Bergmann's 
Chirurgie, and Binnie's Operative Surgery. 

The Annals of Surgery, the American Journal of Surgery, the 
nternational Journal of Surgery, and the Journal of the American 
Medical Association have been prolific sources of information. 

For advice and aid in many ways in the preparation of this book, 
special thanks are due Drs. John J. Kyle, James H. Ford, A. W. 
Brayton, and Gustav Bergener. The original illustrations are the 
work of Dr. Helen Knabe. 

To the publishers, through whose counsel and patient criticism the 
300k has grown into its present form, a grateful appreciation is to be 
expressed. 

J. W. S. 



IX 



CONTENTS 

PART I 



CHAPTER I 

Page 

The General Practitioner as an Emergency Surgeon: His 
Duties and Responsibility: Equipment i 

CHAPTER II 

Emergency Antisepsis. Operation in a Private House .... 6 

CHAPTER III 

Anesthesia 12 

CHAPTER IV 
Sutures; Methods and Materials 25 

CHAPTER V 
Drainage 32 

CHAPTER VI 
Dressings, Bandages, Splints : 35 

CHAPTER VII 
Shock 52 

CHAPTER VIII 
Hemorrhage 57 

CHAPTER IX 

Wounds: General Principles 71 

xi 



Xll CONTENTS 

CHAPTER X 

Page 

Wounds of Special Regions 81 

CHAPTER XI 
Injuries to the Trunk. . , no 

CHAPTER XII 
Gunshot and Other Wounds in Military Practice 133 

CHAPTER XIII 
Gunshot Wounds in Civil Practice 186 

CHAPTER XIV 
Fractures of the Extremities . . 200 

CHAPTER XV 
Compound Fractures 283 

CHAPTER XVI 
Fractures of the Clavicle, Scapula, Ribs, Spine, Pelvis 290 

CHAPTER XVII 
Fractures of the Skull and of the Bones of the Face .... 299 

CHAPTER XVIII 
Injuries to Joints 312 

CHAPTER XIX 
Injury and Repair of Tendons , 347 

CHAPTER XX 
Injury and Repair of Nerves 357 

CHAPTER XXI 
Abscess 375 

CHAPTER XXII 
Philegmon: Acute Spreading Infections 4 21 



CONTENTS Xlll 

CHAPTER XXIII 

Page 

|Acute Osteomyelitis 432 

CHAPTER XXIV 
Ieptic Arthritis 440 

CHAPTER XXV 
Foreign Bodies 451 

CHAPTER XXVI 
Burns, Scalds, and Frost-bite 468 

PART II 

CHAPTER I 
Tracheotomy, Laryngotomy, Esophagotomy 477 

CHAPTER II 

Urgent Thoracotomy. Repair of Injury to the Lungs. Repair 
of Injury to the Pericardium. Repair of Injury to the Heart. 
Puncture of the Pericardium. Pericardiotomy 488 

CHAPTER III 
Empyema — Purulent Pleurisy 502 

CHAPTER IV 
Urgent Craniectomy; Trephining 510 

CHAPTER V 
Mastoid Abscess 522 

CHAPTER VI 
General Technic of Laparotomy 530 

CHAPTER VII 
Laparotomy for Traumatism 537 

CHAPTER VIII 
Appendicitis; Appendicial Abscess; Purulent Peritonitis . . . 557 



XIV CONTENTS 

CHAPTER IX 

Page 

Acute Intestinal Obstruction 577 

CHAPTER X 
Artificial Anus; Temporary, Permanent 589 

CHAPTER XI 
Strangulated Hernia 598 

CHAPTER XII 
Radical Cure of Inguinal Hernia 632 

CHAPTER XIII 
Radical Cure of Femoral Hernia 643 

CHAPTER XIV 
Enterectomy. Intestinal Anastomosis 650 

CHAPTER XV 
Imperforate Anus 662 

CHAPTER XVI 

Torsion of the Pedicle of Ovarian or Uterine Tumors; of the 
Spermatic Cord; of the Pedicle of the Spleen; of the Omentum. 667 

CHAPTER XVII 
Rupture and Hemorrhage of Tubal Pregnancy 675 

CHAPTER XVIII 
Cesarean Section 682 

CHAPTER XIX 
Rupture of the Urethra. 686 

CHAPTER XX 

Acute Retention; Catheterization; Suprapubic Puncture; 
Cystotomy; Urinary Infiltration 698 

CHAPTER XXI 
Suture and Ligation of Arteries 717 



CONTENTS XV 

CHAPTER XXII 

Page 

Practical Amputations 728 

CHAPTER XXIII 

Dilation of the Sphincter Ani; Operation for Piles; Operation 
for Anal Fistula 783 

CHAPTER XXIV 
Phimosis; Paraphimosis; Circumcision; Hydrocele; Castration. . 790 

CHAPTER XXV 
Ingrowing Toe-nail 801 

CHAPTER XXVI 

Removal of Small Tumors 804 

CHAPTER XXVII 

Skin Grafting 807 

Index 813-828 



EMERGENCY SURGERY 



CHAPTER I 



THE GENERAL PRACTITIONER AS AN EMERGENCY 
SURGEON: HIS DUTIES AND RESPONSIBILITY. 

EQUIPMENT 

Surgery is no longer reserved to the elect few. That its beneficence 
shall be denied a place in every practitioner's art is repugnant to the 
spirit of the times. Modern life is complex: every profession and 
every calling has its specific duty to perform. Whether the medical 
Drofession shall continue to play nobly its large part in the social 
drama depends upon the general practitioner. The hope of the 
profession rests in him. But there is a price to pay the age for high 
respect. That price to the medical profession is nothing less than the 
! ulfillment of its therapeutic promise and realization of its surgical 
opportunity. The opportunity is golden; for, with the wonderful 
improvements in surgical technic, the field of emergency surgery, 
that is to say, the indication for immediate intervention, has been 
remarkably broadened and the time finds the public singularly favor- 
able to that form of relief. 

The " horror of the knife," of all that pertains to surgery, has 
become a tradition, like the practice which gave it birth. Indeed, 
the public is trained to expect that, in the face of grave emergencies, 
the practitioner will do something effective; however serious the re- 
quired intervention may be, if it but offers hope, the doctor is expected 
to act. Our predecessors — even those able and willing — of ten found 
their hands tied under such circumstances by the ruling policy of 
"let alone and let die." It is a part of their glory that they conceived, 
planned, and attempted in the face of tremendous obstacles, most of 
the interventions of urgency which are current to-day. 



2 THE GENERAL PRACTITIONER AS AN EMERGENCY SURGEON 

The surgical opportunity, then, of the general practitioner is clear, 
andjiis duty as well. The professional spirit, the humanities, his 
conscience, make it incumbent upon him to know and act. This 
he must do or drop to the rear in the march of progress, which does 
not halt for the timid or unwilling. 

But the task imposed is heavy, the responsibility large; for the gen- 
eral practitioner often finds himself isolated, remote from special 
counsel, perhaps compelled to act alone. That he does not always 
rise to the surgical emergency and do all that he might do even under 
unfavorable circumstances, may often be laid in large part at the door 
of his training. He knows often what he ought to do, yet knows not 
how to do it. Happily the courses of instruction are now generally 
planned to do away with this strange antithesis between theory and 
practice: a theory, modern, scientific, positive; a practice, as Lejars 
says, still often full of error and based on empiricism age-old. 

But this must not be; for, now that the indications for operation are 
exactly defined and one's duty obvious, vague conception of an opera- 
tion as something far away and desperate, must give way to clear 
notions of the resources of surgery, of surgical therapeusis. Every 
doctor must familiarize himself with the technic of interventions 
which he must undertake at times, if he is not to be inexcusably re- 
miss in an almost sacred duty. 

Surgery in one respect is a handicraft, and as such requires its 
certain tools of first necessity. If, as has been said, emergency sur- 
gery always comes in the nature of a surprise, then the surprise will at 
least be less complete if one has an equipment and has it prepared. 

Every doctor should have an emergency bag supplied with mate- 
rials: hand brushes, soap, a fountain syringe, hypodermic syringe, 
catheters, flasks of alcohol, ether, chloroform and carbolic acid, 
bichloride tablets, a package of sterile compresses, sutures, bandages, 
a box of plaster of Paris, and certain instruments. 

Hand Brushes. — -These are almost indispensable for emergency sur- 
gery. They should be kept well wrapped and should be cleansed 
with soap and hot water and sterilized by boiling for one minute before 
using. New brushes should be boiled in soda solution for five to 
ten minutes. If brushes are lacking, one may scrub the hands and 
the field of operation with sterile gauze. In the hospital where the 



ANTISEPTICS 3 

cleansing at the time of operation has been preceded by another dis- 
infection, gauze may be used to the exclusion of the hand brush. 

Fountain Syringe or Irrigator. — -One may use the full rubber out- 
fit or, what is better, a porcelain container and a long rubber tube 
with glass nozzles. It is absolutely essential that the whole be steril- 
ized by boiling. It is nonsense to sterilize, as is often done, the 
cannulae and container, and neglect the tube. The glass nozzles are 
likely to be broken if plunged directly into boiling water or if cooled 
too rapidly. If the porcelain container is used, it may be boiled and 
then singed with burning alcohol. It takes up but little room in the 
bag, and the tube and nozzles may be wrapped up and packed in it 
and the whole wrapped and kept clean and dry. This outfit is al- 
most indispensable, for in many emergencies the only adequate treat- 
ment is by hypodermoclysis or intravenous infusion. 

The Antiseptics. — The alcohol must be kept in a well stopped flask 
and the carbolic acid or lysol, also. The bichloride may be in the 
form of tablets, so that the strength of a solution may be readily 
calculated. The most commonly employed is the formula contain- 
ing mercury bichloride 7.3 gr., citric acid 3.8 gr. This tablet in 1 
quart of water makes a 1 to 2000 solution, which is as strong as need 
be used. One to 3 pints makes a 1 to 3000 solution, and so on. 
Instead of the tablets, one may keep a concentrated solution of bi- 
chloride in alcohol. 

Bichloride of mercury, 3j- 

Alcohol, 5j- 

One teaspoonful to a quart of water makes a 1 to 2000 solution; 

One teaspoonful to 3 pints, 1 to 3000, etc. 

Instead of the bichloride, the biniodide of mercury, 1 to 4000 may 
be used. 

Iodine grows constantly in favor in spite of certain drawbacks. A 
four ounce vial of the tincture supplies for many sterilizations. Its 
stain on the hands and linens may be removed by moistening with 
ammonia or solution of hyposulphite of sodium. 

Anesthetics. — One should keep on hand at least one pint of ether 
and four to six ounces of chloroform. Cocaine for local anesthesia 
is best kept in tablet form and the solutions made extemporaneously. 



4 THE GENERAL PRACTITIONER AS AN EMERGENCY SURGEON 

For example, 2K-grain tablets of cocaine to i teaspoonful of sterile 
water makes a 2 per cent, solution; 43^-grain tablets of a tea- 
spoonful of water makes a 4 per cent, solution; ioM-grain tablets, 
a 10 per cent, solution. This is not exact, of course, but furnishes a 
good working rule for the emergency. Novocaine is less dangerous 
than cocaine and in M or 1 per cent, solutions may be used in large 
quantity and with excellent effect. Ethyl chloride for local freez- 
ing is put up in small containers convenient for the emergency 
bag. 

Sterile Gauze. — Too frequently the practitioner commits the error 
of depending upon absorbent cotton for his sponges and compresses. 
Absorbent cotton, as found on the market, is scarcely ever aseptic. 
Even so, it is almost certain to be contaminated in getting it out 
of the package. A supply of sterile gauze is one of the best means of 
promoting an aseptic operation. It should be kept in a hermetically 
sealed package of metal or glass. 

In lieu of the gauze compresses ready sterilized, one may carry a 
supply of ordinary gauze which can be cut into appropriate sizes, and 
sterilized at the time of operation. It is a good idea to cut two sizes; 
a small for compresses and wipers, a larger to cover the field of 
operation. All these pieces should be folded once and the borders 
hemm ed. A ball of cotton may be hemmed in between the layers, 
which makes a still better sponge. The compressed package of 
gauze as supplied by Borroughs and Welcome is especially appro- 
priate to the small emergency bag. Once accustomed to its use it 
seems almost indispensable. 

Sutures and Ligatures. — If these materials are not already sterilized 
and in a special package or container, such as a sealed tube of 
alcohol, catgut must be ruled out, for its preparation takes too 
much time. One should take care to have several sizes of silk, espe- 
cially the o and 00; for these are the sizes required in intestinal 
work. Silk and silkworm-gut may be sterilized as needed. 

Catheters and bougies should be kept in a metallic box. Rubber 
and metal catheters are always readily sterilized by boiling. Rubber 
catheters deteriorate rapidly unless properly cared for. They 
may break unexpectedly, the result of an unnoticed change in 
quality, and a piece be left in the bladder. 



CARE OF INSTRUMENTS 5 

Drainage Tubes. — These should be preserved in a box or bottle 
which may be boiled thoroughly before opening. 

Plaster should be kept in a tin box with tight cover and may be 
loose or already rolled. A supply of roller bandages is, of Course, 
always kept on hand, from which the plaster bandages may be 
made. 

Instruments. — -Any list which might be enumerated must, of course, 
be subject to the widest variation. But the feeling of greatest 
confidence goes with the consciousness of having the necessary things 
with which to act. On the whole, the doctor should pride himself 
upon the completeness of his outfit, rather than upon his ability to 
improvise. One should have as the minimum: scalpels, two sizes 
of amputating knives, scissors, grooved director, dissecting forceps, 
artery forceps — the more the better — two retractors, a saw, a bone 
chisel, needle holder and needles, tracheotomy tubes, and an Esmarch 
tube. The instruments most frequently used may be put together 
in a small metal case, while the others may be kept in larger cases, 
or wrapped, or rolled up in a bundle. 

Cleaning instruments and preserving them from rust is a matter 
of no small importance. After each operation they should be taken 
apart, scrubbed with soap and warm water, wiped with gauze 
saturated with alcohol, and dried thoroughly. If the cleansing has 
been delayed, it may be necessary to immerse them for a short 
time in a solution of potash, and finally cleanse in the manner de- 
scribed. If any stains still persist they should be polished with 
chamois skin. 

Formaldehyde, certain acids, and iodine in too close proximity, 
tarnish and spoil instruments in spite of care. 

A dish or two of calcium chloride in the instrument case will 
absorb moisture and tend to prevent rusting. Too often the practi- 
tioner neglects his instruments because, perhaps, not often used; 
and, in the emergency, he finds himself with knives rusty and with- 
out an edge, scissors that will not cut, and forceps that have no 
grip. He will certainly gain time by spending a little time in carry- 
ing out these small details in the care of his tools. 



CHAPTER II 

EMERGENCY ANTISEPSIS. OPERATION IN A PRIVATE 

HOUSE 

The preparation for an urgent intervention outside of an operating 
room resolves itself into a question of asepsis or antisepsis, and 
around this point gathers a multitude of details. But it is necessary 
only to proceed systematically and intelligently to achieve excellent 
results. 

The time was when the idea prevailed that an aseptic operation 
was scarcely possible outside a hospital. This was a harmful notion 
which restrained many a practitioner from an effort that might have 
saved his patient's life. Every day it is demonstrated that aseptic 
work is not peculiar to formal operating rooms. 

Bonney, of Philadelphia, writes that he has done many major 
operations in the homes of the poor in the midst of the most unsurgical 
surroundings; nevertheless, the results have been excellent. Most 
of these operations were for urgent abdominal, pelvic, or genito- 
urinary disease, and though such work is often time-consuming 
and laborious, yet it shows what can be done in the case of necessity. 

Garrison of Birmingham (Ala.) concludes a useful paper touching 
this subject with the statement that of a thousand cases operated in 
the last ten years in the patients' homes the mortality rate was zero, 
except that in a series of abdominal gunshot cases three died. (Amer. 
Jour. Surg., Aug., 19 14.) 

Van der Walker (Month Cyclopedia of Pract. Med., Aug., 1906) 
says that for thirty years he has operated in farm houses through- 
out central New York with as good results as those obtained in the 
hospital with which he was connected for many years. He goes 
further and concludes that, for many reasons, it is desirable that 
there should be a return to more home operating, and that the 
hospital ought to go back to its original purpose, the care of the 

6 



PREPARATION OF MATERIALS 7 

homeless and sick poor, and not invade the home with the arrogant 
assurance that only within its walls can the surgical case be cared 
Ifor. 

But this is aside from the main point: the practitioner may feel 
\assured that with decision, knowledge, and system, even under ap- 
parently unfavorable circumstances, he can nearly always realize an 
\efective asepsis. 

AsLejars says, everywhere one finds water, fire, and linen; add salt 
and usually carbonate of soda: with these one may accomplish a 
sufficient sterilization of the instruments, the hands, the field of opera- 
tion and the dressing. But it requires a will to do all the work, to 
proceed with method and, above all, quickly, through the minutiae 
of preparation. One should have a plan in mind and Lejars offers 
a model which, of course, can be modified to suit the circumstances 
and the operation. Suppose a major emergency, with every detail 
of the preparation to be supervised: 

First Step. — -Have a fire started. Have the available receptacles 
assembled. Review the stock of linens if you do not have gauze 
or muslin. Freshly laundered handkerchiefs and napkins (without 
fringe) furnish material for excellent compresses and coverings for 
the field of operation. Secure one or two large kettles — -a copper 
wash-boiler— for boiling the water for the operation. Secure three 
smaller receptacles such as enameled stewing-pans: one, for boiling 
the instrument and sutures; another, for the brushes, irrigator, 
nozzles and tube, etc. ; the third, for the compresses and tampons. If 
possible, boil also the dishes or basins selected to hold the instruments 
and the solutions needed during the operation. It is best to have a 
dish or bowl for the instruments, one for the tampons and compresses, 
one for the sutures, and two hand basins for sterile water and 
bichloride solution. The boiling must be prolonged at least a half 
hour to be sure of sterilization. It is a good plan to add a teaspoon- 
ful of salt to the quart of water containing the compresses which are 
to be tied up in a towel to facilitate their removal ; and to add a tea- 
spoonful of washing soda to the water in which the instruments are 
to boil, since it more readily removes grease or blood, makes the 
temperature slightly higher, and prevents rusting. The knives 
should be wrapped in soft gauze to prevent dulling; still better 



8 EMERGENCY ANTISEPSIS 

edged instruments should not be boiled at all but merely immersed! 
in alcohol for some time previous to the operation. The instruments 
ought not to be put in until the water is boiling, as otherwise they 
are likely to be tarnished. If it is necessary to boil the instruments 
and suture material together, the soda should not be added, since it| 
rapidly ruins both silk and silkworm-gut. Even better than boil- 
ing water for sterilizing instruments is hot oil — olive oil, for example | 
— since its boiling-point is a higher than that of water. The vessel 
containing the oil can be set in another of cold water and instruments 
may soon be taken from the oil ready for use. This oil may be used 
again many times. Five minutes of actual boiling is sufficient to 
sterilize instruments. When once the sterilization is under way 
proceed to the operating room. 

Second Step. Prepare the Operating Room and Table. — If there is 
any choice, select the best lighted and largest room. If it is at 
night, arrange for the illumination. Do not displace the furniture 
except to make room for the operating table, two small tables, and 
room to "turn about." An extensive "clearing for action" does 
more harm than good, for by jerking down the curtains, rolling the 
furniture around and sweeping, one stirs up the dust, accumulating 
perhaps for months. 

It is preferable simply to sprinkle the floor or wipe with a wet 
cloth. To be sure, if one has several hours in which to prepare, then 
the room may be emptied, the floor covered with moist sheets and 
the walls sprayed, as Quenu suggests, with peroxide, the tables placed 
and the room closed until the time of operating. 

It is never a good idea to use the patient's bed for an operating 
table, although the first preparation, as the shaving, may be begun 
there. The dining table can usually be pressed into service, covered 
with a blanket and that with an oilcloth. A table may be im- 
provised from two wooden trestles with planks laid across and 
covered like the table. Of the two small tables required, the one on 
the assistant's side will hold the compresses, sutures, etc.; the other 
on the operator's side will hold the instruments. 

Now give the patient the preliminary preparation. Shave the 
parts always when possible, first lathering with soap and hot water. 
The razor is almost indispensable as an agent of disinfection, for it 



PREPARATION OF THE HANDS 9 

moves the hair and the superficial layer of the epidermis. It is a 

:ommon fault to be too sparing with its use. In operations on the 

>kull, the whole scalp should be shaved. The shaving may be done 

iter the patient is anesthetized; but, as a rule, everything possible 

Ishould be done to curtail the anesthesia. If the operation is likely to 

be prolonged, wrap the lower limbs in blankets, and speak for hot 

lirons or water bottles. 

Third Step. — Everything having boiled sufficiently, carry the 
vessels into the operating room and empty the contents of each into 
its special receptacle, which of course must first be sterilized. 

If these bowls have not been boiled, as previously directed, now 
is the time to sterilize them by singeing with burning alcohol. Into 
each pour two or three spoonfuls of alcohol and set it on fire, in the 
meantime tilting the dish in various directions so that the flame is 
brought in contact with the whole inner surface. When this is 
done, lift the compresses and instruments out of their boilers, place 
them in these sterile dishes and cover them with an antiseptic 
solution. This protects them from possible contamination until 
the operation begins. Do not open the bag of compresses till 
needed. Remember to use only a sterile dipper, if necessary to 
dip out the sterile water in preparing the various solutions. 

Fourth Step. — Direct the assistant to begin the anesthesia, and 
now prepare your hands. AsLejars remarks, this is a " science and 
art," the first duty of the surgeon. They are not to be prepared by a 
desultory rinsing in soapy water, or parboiling with a hot antiseptic 
solution, but by a patient and systematic scrubbing. Get your 
sleeves rolled up and pinned. Have before you two wash basins, 
one with hot and the other with cold sterile water. Pare the nails. 
Begin with soap and hot water. Lather the arms up to the elbow, 
and rub the soap in until the skin seems saturated and soft. Then 
begin with the brush; scrub the palms, the dorsum of the hand, be- 
tween the fingers, all about the nails. One need not rub the skin 
off, to be sure, but the disinfection must be complete. The water 
should be changed several times, if possible; next rinse in cold sterile 
water and then rub vigorously with alcohol to remove all the oils 
in the skin; finally soak in bichloride solution. The cleansing will 
probably occupy ten minutes. The antiseptics used vary with the 



IO EMERGENCY ANTISEPSIS 

operator, but, after all, it is the soap and hot water which is most 
important. At the Indianapolis City Hospital the routine is scrub 
bing with soap and water; rinsing in lysol; rinsing in sterile water 
and finally scrubbing thoroughly with gauze saturated with alcohol. 
In an emergency one might feel safe in using the alcohol alone. 

Alcohol as a disinfecting agent has the disadvantage that it fixes 
the blood of the operation on the skin but this may be removed by 
peroxide or a warm solution of sodium carbonate. 

Rubber gloves are almost universally employed in hospital clinics. 

Gloves are trying to the temper where the surgeon must manage 
them himself. One plan is to fill them with the solution used in 
the operation and which is squeezed out after the hand is in place 

Burmeister says that just before putting on the gloves, he rubs 
two tablespoonfuls of bolus alba with a little water over his hands 
so that they are covered with the thick paste, enabling the glove to 
be pulled on and off easily, protecting it against tearing and be- 
sides the paste has a soothing action on the skin. (Zent. blatt. f . 
Chiriirg, Leipsic, Feb., 1913.) They are probably an extra guar- 
antee against infection, but are by no means indispensable. As 
good plan as any, perhaps, is to use them always where infective 
processes are likely to be met with; thus the operator is protected; 
and, besides, his hands are kept free from septic agents which might 
be difficult to remove. 

Fifth Step. — In the meantime the anesthesia has progressed. 
When it is well under way, prepare the field of operation, which we 
assume has been previously shaved, by scrubbing with soap and 
water, followed by alcohol or ether and bichloride solution. Har- 
rington's solution is much employed and consists of 

Mercuric chloride, .8 g. 

Acid hydrochloric, 60 c.c. 

Water, 300 c.c. 

Alcohol, 640 c.c. 

Iodine is quite commonly used and for emergency work is prefer- 
able. In this case the skin is shaved dry, scrubbed with ether or 
alcohol and the plain Tr. of iodine applied and allowed to dry. 
Another application is made and when it dries the sterilization is 
complete. 



DISINFECTION OF THE SKIN II 

In the case of the abdomen, particularly, the iodine should be 
mally removed by use of alcohol. But, whatever method may be 
mployed, the disinfection of the skin must he, in every respect, as 
horough and vigorous as that of the hands, and must extend well beyond 
he proposed line of incision in all directions, for one can never tell 
vhere the incision may finally end. A large area is almost as 
apidly prepared as a small one. For example, in laparotomies 
he whole abdomen should be included, as well as the lower half of 
he thorax. In hernia operations, the abdomen as far as the um- 
ilicus, the groin and the genitals. In amputations of the leg, the 

thigh should be included in the cleansing; and in amputations of 

the thigh, the whole region of the pelvis. 
Again wash your hands. An untrained assistant changing the 

bowls may spoil the sterilization by getting his fingers or thumbs 

inside. Direct him how to lift and carry a bowl with his palms 

against the outside. 

Having completed the final cleansing of the hands, cover the 

field of operation on the four sides with four sterile towels or large 

compresses and fasten them with sterile safety pins or artery forceps. 
Time gained by relaxing in the least any of these precautions of 

asepsis and antisepsis, is irretrievably lost; it is the operation, now 

begun, which must progress rapidly. 



14 ANESTHESIA 

Beware at this time of sudden blanching of the face, of dilated 
pupils, of weakened pulse, or disturbed breathing. If these symp- 
toms arise, withdraw the anesthetic and prepare for artificial respira- 
tion. The patient is not ready for the operation and yet he may die 
in this stage. 

Pallor and dilated pupils often precede vomiting, but when the 
pulse and respiration are good, the nausea is to be quieted by more 
chloroform. 

When the reflexes are finally abolished, the pulse should be full, 
though perhaps a little slowed, the respiration quiet and regular, 
the pupils slightly contracted, and the face moderately pale. Any 
marked deviation from this standard during the operation is a 
matter for concern. 

Weak heart action, uncertain respiration, dilated pupils, deep 
pallor or cyanosis, mean approaching paralysis of the automatic 
centers governing the circulation and respiration, and the anesthetic 
must be withdrawn until the symptoms improve under measures 
employed to stimulate. 

In the case of the average adult, one and one-half to two ounces 
should be sufficient for the first hour and much less subsequently. 
Children and the debilitated require less. 

Ether has the disadvantages in emergency work that it is danger- 
ous to use near a light or fire, and that its administration is a little 
more complicated; but, beyond that, its anesthesia is never at- 
tended by sudden death in the early stages, as is that of chloroform. 
It is followed by less shock after abdominal operations or other pro- 
longed intervention. Bronchial affections are its chief counter- 
indications. 

Ether may be administered by the drop method using the same 
mask as for chloroform (Fig. 2) and the same general method (Fig. 
3). Or an inhaler may be fashioned out of a newspaper rolled into 
a cone, cotton or gauze fastened in its apex, on which the ether 
is poured. Begin with a drachm; let the patient get accustomed 
gradually to the ether, diluting it well with air by holding the inhaler 
an inch or so from the face and gradually approaching. In that way, 
the feeling of suffocation is avoided. As the patient approaches 
unconsciousness, hold the mask closely so as to shut out the 



ETHER ANESTHESIA 



15 



air, and the stage of anesthesia will be quickly reached without 
excitement. 




Fig. 2. — Administration of ether by the drop method. Mask, with and without gauze 
covering. Appliance for regulating flow, unattached, to right of ether can. 



If one proceeds timidly at this stage, the anesthesia will be hard 
to obtain and much more ether will be required. Once the reflexes 




Fig. 3. — Administration of ether. Appliance regulating flow attached to can. 

are abolished, use small quantities, frequently applied. The acci- 
dent most to be feared is respiratory paralysis. 



1 6 ANESTHESIA 

The signs indicating the favorable progress of ether anesthesia 
during the operation are: pulse full and regular; respiration deep and 
slightly snoring; face flushed; and pupils slightly dilated. Cyanosis 
is the signal for more oxygen. Any disturbance of the respiration 
demands immediate attention. Occasionally patients will be 
found who do not take ether well, but who will take chloroform with- 
out the least untoward effect. 

TREATMENT OF THE ACCIDENTS OF ANESTHESIA 

Certain measures are recommended as forestalling the dangers 
of anesthesia; though they are, as a rule, more appropriate to the 
general surgery of hospitals. 

A preliminary gastric lavage will save embarrassment in certain 
cases. In fact, this should be an invariable rule, when compelled 
to operate on patients who have eaten only a short time previously. 
A preliminary subcutaneous injection of normal salt solution will 
sustain the patient in the cases of anemia and grave septic infection. 

Many surgeons precede a chloroform anesthesia by hypodermic 
injection of morphine or strychnine, or of morphine and atropine, 
thirty minutes before the anesthesia. This is desirable especially in 
operations on regions in which the reflexes are more active, for there 
is scarcely a doubt that some of the circulatory disturbances under 
chloroform are reflected from the field of operation. This is true of 
the testicle, the spermatic cord, the anus, and the peritoneum. None 
of these methods lessens the anesthetist's responsibility and duty to 
watch every point. 

If the circulation grows weak, the pulse small, rapid, compres- 
sible, due to the effect of the anesthetic agent and not to shock or 
hemorrhage, withdraw the agent and lower the head, draw out the 
tongue and begin artificial respiration, and the danger is usually 
soon passed. 

Hypodermic injection of stimulants, such as strychnia or camphor- 
ated oil often do good under these circumstances; but when the 
circulation is paralyzed and syncope has supervened, their use is 
illusory. Do not waste time preparing them, though an assistant 
may do so; but proceed to make rhythmic traction on the tongue, 









ARTIFICIAL RESPIRATION 



17 



and artificial respiration, both being carried out methodically. If 
an assistant is at hand, carry out the two measures simultaneously; 
otherwise, try the tongue traction first, or at least get it pulled out 
well. Traction of the tongue to do good, must be rhythmic. The 
tongue must be caught up carefully with forceps and no force must 
be used. Often the tongue is seriously injured by the feverish pulls 
of the agitated operator, who has quite forgotten that the maneuver 
is effectual only when rhythmic. 

The artificial respiration must likewise be rhythmic. 

Grasp the patient's elbows and draw them gently and steadily 
upward until they meet above the head. The pectoral muscles are 
put upon the stretch and the chest expanded and inspiration pro- 
duced. At the same time the tongue is drawn outward (Fig. 4). 




I Fig. 4. — Stage of inspiration. Tongue should be drawn out with this movement. {Stewart.) 



The arms are next brought with a steady movement to the chest 
wall and the diaphragm compressed. (Stage of expiration.) At 
the same time, the tongue is permitted to retract (Fig. 5). 

These movements are to be repeated at the rate of about twenty 
per minute and should be persisted in without intermission for at 
least a half hour before giving up hope of resuscitation. 

Direct compression of the heart is a procedure of real value and it 
may often be readily managed through the abdominal walls. In the 
case of abdominal operations, the hand may be passed up to the 
diaphragm and the heart seized and kneaded in that manner. 

The vomiting after anesthesia is often troublesome and is usually 



i8 



ANESTHESIA 



in direct ratio to the amount of the agent used. Every effort should 
be made to hasten its elimination from the blood by keeping the skin 
warm and active, and helping the kidneys with saline enema ta. 
These enemata also diminish thirst. Warm soda water drunk freely 
helps to wash out the stomach and thus hastens relief of active vomit- 
ing. Five to fifteen drops of aromatic spirits of ammonia hypo- 
dermically, or, well diluted, by mouth, often does good. Both 
these agents probably do good by relieving acidosis which is a large 
factor in producing post-anesthetic troubles. 




Fig. 5. — Stage of expiration. Tongue permitted to drop back in mouth. (Stewart.) 

If there are evidences of beginning acute gastric dilatation, gastric 
lavage must be used early. 

Other forms of general anesthesia will not often be of service in 
emergency practice for obvious reasons, however valuable they may 
otherwise be. It is hardly necessary, therefore, to consider nitrous 
oxide or ethyl chloride and their congeners; or general anesthesia by 
way of the rectum, which promises to be of value in operations on 
the face, mouth, neck, and thorax; or hedonal and ether intraven- 
ously which has been the subject of good reports. 



LOCAL ANESTHESIA 

The doctor, isolated and without assistants, will many times find 
aid and comfort in local anesthesia by hypodermic injection; but 
to be efficient, it must be properly induced. A definite technic must 



LOCAL ANESTHESIA 



19 



be followed. Either cocaine or stovaine may be used, the latter 
safer, the former slightly more active, the two used alike. Having 
determined the line of incision, pinch up a fold of skin (Fig. 6), 
introduce the needle at one end of the line and push it into the skin, 
but not through the skin. The injection is intradermal (Fig. 7). 




Fig. 6. — Local anesthesia; method of introducing needle. (Veau.) 

As the needle is steadily advanced, the syringe is emptied slowly, 
and the line of injection is indicated by the formation of a wheal. 
When the needle has entered its length, it is reintroduced in the same 
line and in advance of the previous puncture, but within the area 
already anesthetized. In this way, only the first puncture is felt. 
When the line of incision has been infiltrated in this manner through- 




Fig. 7. — Local anesthesia; the needle does not penetrate the whole 
thickness of skin; " intra-dermic " injection. (Veau.) 

out its entire length, it will be completely insensitive after a wait of 
one to two minutes. The width of the zone of anesthesia will de- 
pend upon the rate of movement of the needle through the skin 
(Figs. 8, 9). It need hardly be said that the needle and solution must 
always be sterile. It is better to pour the solution out into a sterile 



20 ANESTHESIA 

dish or glass, rather than to aspirate it from the bottle. The air 
must be forced out before the needle is introduced; care must be 
taken not to throw the injection into a vein. 

When an area, rather than a line, is to be infiltrated, as in case 
some dissection is anticipated, Schleich's method is better, in which 
the needle is plunged directly into the tissues and a sufficient quan- 



A/1. 

Fig. 8. — Local anesthesia; the Fig. 9. — Local anesthesia; the 

zone of infiltration is narrow zone is broad when the needle is 

when the needle is pushed for- introduced slowly. (Veau.) 
ward and emptied rapidly. 
(Veau.) 






tity of the solution discharged to raise a wheal. The needle is then 
reintroduced alongside the wheal for another injection. The anes- 
thesia may be renewed from time to time during the operation. 
Schleich's formula is as follows: 



NO. I, STRONG. 




Cocain. hydrochlor., 


gr. iii. 


Morphin. hydrochlor., 


gr- %. 


Sodii chloridi., 


gr. iii. 


Aq. destillat., 


5 iii, 5 iiss 


NO. 2, NORMAL. 




Cocain. hydrochlor., 


gr. iss. 


Morphin. hydrochlor., 


gr. 2 / 5 . 


Sodii chloridi., 


gr. iii. 


Aq. destillat., 


§ iiiss. 



LOCAL ANESTHESIA 



21 



NO. 3, WEAK, 



Cocain. hydrochlor., 
Morphin. hydrochlor., 
Sodii chloridi., 
Aq. destillat., 



gr. H. 
gr. iH. 

gr. iii. 
§ iiiss. 



Two or three drops of a 50 per cent, solution of carbolic acid may 
be added to preserve. The solution must be kept cool. Twenty- 
five syringefuls of Number 1, fifty syringefuls of Number 2, and 
500 of Number 3, may be used without danger. Novocaine in y 2 
per cent, solutions is, we think, even better than Schleich's solu- 





Fig. 10. — The finger may be anes- 
thetized by a circular injection at its 
base. (Veau.) 



Fig. 11. — Complete anesthesia of fin- 
ger induced by deep injections on each 
side. The upper and lower needle, 
represent the primary circular injections. 
(Veau.) 



How- 



tion, though in equal quantities slightly more dangerous, 
ever, smaller quantities are required. 

The patient should not be permitted to sit up during the anes- 
thesia if cocaine is used, for it exposes him to the risk of heart 
failure. It is safer to keep him recumbent for a half hour or so after 
the operation. 

If a finger or toe is to be amputated, first make an anesthetic 
ring involving the skin only (Fig. 10), and follow this with two deep 
lateral injections to obtund the main nerve trunks (Fig. n). 



22 ANESTHESIA 

SPINAL ANESTHESIA 

Spinal anesthesia with stovaine can only very rarely be of use to 
the general practitioner in emergency work, although it is of value 
under certain circumstances. It is of special use in operations in- 
volving the anal and perineal regions. By this method the heart 
and lungs are not dangerously affected. It is a solace to those pa- 
tients whose dread of a general anesthesia is greater than their dread 
of death, and who will refuse operations of absolute necessity rather 
than take ether or chloroform. The most definite contra-indica- 
tion is uncertainty of asepsis, since the chief danger of the procedure 
is meningitis. It should not be used in the young, in advanced 
arterio-sclerosis, in cases of septicemia, or central nervous disease. 
The average duration of the analgesia thus produced is one hour. 
The effects are fairly uniform; the chief after-effects are headache 
and nausea. One of the author's patients, operated for hernia 
under spinal anesthesia complained for several months of loss of 
sensation in the penis and rectum, though not materially interfering 
with the functions of either. The preparation employed by the 
author is that of Chaput: stovaine, 10 gr.; sodii chloridi, 10 gr.; 
distilled water, i c.c. This is put up in hermetically sealed am- 
poules, each containing i c.c. of the solution, which is sufficient for 
an injection. Bier regards cocaine as the most dangerous and 
tropacocaine the safest, and this latter he employs in doses of M 
to i grain. The syringe employed must be easily sterilized and 
with a capacity of at least 2 c.c. A long platinum needle is best. 
A special glass syringe with needle for this injection can be readily 
secured. 

Technic. — The patient's back, the instruments, the solution, the 
operator's hands, are duly prepared. The needle is attached to the 
syringe and the contents of an ampoule aspirated and the needle 
detached. The patient sits bending forward to make the lumbar 
spines more prominent and to enlarge the intervertebral foramen 
which is to be traversed by the needle. Locate the iliac crests and 
mark their position with the finger nails. The line connecting the 
highest points of the iliac crests intersects the fourth lumbar spine 
the tip of which is next to be located in the middle line. The tip of 



SPINAL ANESTHESIA 23 

the next spine above the third is now marked and between these 
two points the puncture is made. Hold the left index finger on the 
third lumbar spine. Hold the unattached needle in the right 
hand, and enter its point just below the third lumbar spine a little 
to the right of the middle line, and push it slightly upward and in- 
ward at an angle sufficient to meet the spinal membranes in the 
middle line. Pushing the needle steadily upward and inward, it 
can be felt to reach the resisting ligamentumsubflava and, finally, the 
puncture of the membranes is announced by the flow of spinal fluid 
from the needle. Hold the finger over the outlet until the syringe 
can be attached; then let sufficient fluid run in the syringe to make 
2 c.c; in other words, make a mixture in the syringe containing 
equal parts of stovaine solution and spinal fluid. The clear spinal 
fluid becomes milky on meeting the anesthetic solution. Now 
slowly inject the mixture, and when the syringe is emptied, with- 
draw the needle with a rapid movement and seal the puncture 
with collodion. It will require no further attention. 

Have the patient lie down and now prepare for the operation. 
In ten to fifteen minutes the anesthesia begins. The patient 
complains of a pricking sensation in the feet and numbness in the 
legs. A pinch or a pin prick will be felt but will not be painful. If 
the pain becomes too severe in the course of the operation, a little 
chloroform or ether can be employed. If the anesthetic zone does 
not extend high enough, incline the body slightly, head downward. 
During the operation the patient's face is likely to be congested and 
his head will throb. Afterward there is likely to be a severe head- 
ache for a little while and perhaps some nausea. 

The site of puncture may be numbed with cocaine, so that the 
spinal injection is painless. If the point of the needle engages 
against the vertebra, withdraw slightly and change the direction 
as the judgment dictates. The most common mistake is in di- 
recting the needle too much upward. Only very rarely will one fail 
to reach the spinal canal if the landmarks are well defined. 

Jonnesco has been the great advocate of this form of anesthesia 
and reports its use in 2500 cases. He believes now more than ever 
that unlike ether and chloroform there is no contra-indication and 
that it is the anesthetic of the future. (Presse Medical, Oct., 1913). 



24 



ANESTHESIA 



Murphy referring to this and other of the newer forms of anesthesia 
wisely suggests that considering the safety and simplicity of the 
ether drop method the mass of the profession should await larger 
experiences by those who originate and are best fitted to work out 
the destiny of these newer forms. (Practical Medical Series, 
Vol. ii, 1914.) 



CHAPTER IV 

SUTURES; METHODS, AND MATERIALS 

Sutures are applied for the purpose of maintaining the coapta- 
:ion of divided structures. This is necessary to facilitate repair 
and restore function. Suturing serves the additional purpose of 
checking hemorrhage from the smaller vessels. There is no part 
of the surgeon's technic that deserves more attention than the se- 
lection and use of sutures. It is of special importance to the emer- 
gency surgeon who faces infection in every direction. His suturing, 
however, he may absolutely control and make aseptic, and this 
may be the only difference between success and failure. 

Various materials are used, some quite commonly, others rarely 
and for a certain purpose; catgut, silk, silkworm-gut, silver wire, 
kangaroo tendon, and horsehair. The three first named will meet 
all the requirements of the emergency surgeon. 

No material is available which does not have a certain strength 
and which cannot be made aseptic. For emergency work, these 
materials must be already prepared. The creation of a proper 
suture from the raw material is a matter of time and care. 

The general practitioner will do better to buy his sutures pre- 
pared in form available for immediate use, being first assured that 
they come from a reliable source and are put up in a manner to 
keep them sterile. Much suture material on the market has neither 
of these qualifications. 

Silk has the advantage of lending itself to emergency steriliza- 
tion by boiling and immersion in an antiseptic solution, nor is it 
readily contaminated when once sterile; but it should not be boiled 
in soda solution, which makes it brittle. It has the disadvantage 
of not being absorbable. It may be used in buried sutures, but its 
usefulness in that respect grows more and more limited as the art 
of sterilization and preservation of catgut improves. It may be 



26 SUTURES, METHODS AND MATERIALS 

used in interrupted skin sutures, suture of nerves, of tendon, and of 
the intestine, but muscular tissues do not tolerate it. 

Catgut is the ideal material for the buried suture. The chromi- 
cized gut has ample strength and is so prepared as to resist absorp- 
tion in a certain tissue for an approximate time; but it should be re- 
membered that occasionally chromicized gut becomes practically 
unabsorbable and, acting as a foreign body, gives rise to persistent 
sinuses. With a little attention to this detail, a suture may be 
selected which will resist absorption until repair is complete. Plain 
catgut can be used in those tissues only which rapidly unite. It is 
ideal for suturing the peritoneum and for ligating vessels except the 
very large ones. It is very easily contaminated. Where there is 
pus it should never be used as a buried suture. The three qualities 
which the catgut suture must possess are: sterility, tensile strength, 
and absorbability. If a certain brand of catgut produces stitch- 
abscess persistently; if, properly used, it still breaks inopportunely; 
if it refuses to be absorbed, then there is something wrong with its 
manufacture. The occasional surgeon lacking opportunity to test 
all the brands, must therefore fall back upon the manufacturer's 
reputation and guarantee. Absorption of catgut occurs in this 
manner: at first the fibers un twirl and grow loose and finally become 
pulpy at which stage the suture has no tensile strength and is a 
foreign body which is gradually replaced by connective tissue, a 
process which is sometimes exceedingly slow. Even sterile catgut 
once degenerated into a gelatinous compound becomes a nidus 
for bacterial growth. Absorbability is therefore as important as 
sterility. 

Watery solutions and certain chemicals as bichloride render cat- 
gut brittle and weak. 

Silkworm-gut is very strong, non-elastic, non-absorbable, readily 
sterilized, and is much employed where the wound is large and deep 
and the tissues tend strongly to spread apart. Most surgeons employ 
it to suture the skin and fascia after laparotomy. It should be 
kept in various sizes. 

The pagenstecher celluloid linen is in high favor with some sur- 
geons; it is more flexible than silkworm-gut and absorbs moisture 
without softening. 



■ 



THE CONTINUOUS SUTURE 



27 




Fig. 12.- 



-The quilted suture. 
(Moullin.) 



The methods of suturing adapted to emergency surgery are the 
interrupted suture and the continuous suture. Others occasionally 
employed in general surgery are the quilled, the quilted (Fig. 12), 
the twisted, and the button sutures. 

The continuous suture is used in aseptic 
wounds only. Therefore, accidental wounds 
will only, on rare occasions, permit its em- 
ployment. It has the advantage of being 
ivery rapidly applied, but is less sure than 
the interrupted suture. A little practice is 
essential, for it is not altogether easy. Its 
success depends largely upon the assistant. 
I This is the mode of making the con- 
tinuous suture: Commence by passing the 
suture at the upper angle of the wound. 

Make three successive knots. Two are sufficient for catgut. The 
short thread is caught in forceps and retained till the suture is 

completed, at which time it is cut off 
close to the knot (Fig. 13). 

The needle traverses, successively and 
obliquely, first the one lip of the wound 
and then the other; each time the assist- 
ant seizes the thread at the point of 
emergence, and holds it tightly until the 
surgeon makes a new point of emergence, 
when the assistant takes a new hold. 
In this manner, the tension of the suture 
is made absolutely uniform. 

The mode of arrest of the continuous 
suture is important. In making the 
terminal knot, the suture must not be 
fig. 13.— Method of making a allowed to relax. To accomplish this, 
continuous suture. Assistant the sur p- e0 n slips the index finger in the 

holding the suture tight while the ° * " 

needle is passed again. (Veau.) last loop instead of pulling the thread all 

the way through, as was done with all 
the others. Traction with this finger holds the line of suture 
tight while the terminal thread on the one side is knotted three 
times with this loop on the other side (Figs. 14, 15). 




28 



SUTURES, METHODS AND MATERIALS 





Pig. 14. — Completing the 
continuous suture; holding 
the suture tight with finger 
through loop while getting 
ready to tie. (Veau.)" 1 



Fig. 15.— Method of ty- Fig. 16.— Continuous su- 
ing completed continuous ture interrupted in its course 
suture. (Veau.) " (Hartmann.) 





Fig. 17. — Method of 
interrupting the con- 
tinuous suture in its 
course. Needle passed 
back under last loop. 
(Veau.) 



Fig, 18.— T h e 
needle has been 
passed through the 
loop which is drawn 
down tight and the 
suture proceeds as 
before. (Veau.) 



Fig. 10. — Method of passing deep inter- 
rupted sutures. (Veau.) 



THE INTERRUPTED SUTURE 



2 9 



If the continuous suture is long, its stability is insured by crossing 
Le threads at the middle of the line of suture (Fig. 16). The 
Lture is thus interrupted at its middle in this manner: the needle is 





Fig. 20. — Tying interrupted sutures. 
Forceps everting lips of wound to se- 
cure coaptation. (Veau). 



A/' 



Fig. 21. — Method of passing 
superficial sutures. (Veau.) 



simply passed back under the last loop, at the time care being taken 
that the suture does not slip. The succeeding steps are the same 
as before (Figs. 17, 18). The suture 
completed, the loose ends are cut off 
close to the knot. 

The interrupted suture is generally 
employed in suturing the skin, and 
may be of silk, silkworm-gut, silver, 
etc. It must not be absorbable. 
These sutures may be placed deeply 
or superficially, in the one case where 
there is much tension, in the other 
for mere approximation. The deep 
sutures are placed two or three cen- 
timeters apart. 

The needle is entered one centimeter from the edge and emerges 
the same distance from the other side. The thread is concealed 




How to do It, 



How nob to do it 



Fig. 22. — Sutures must not be tied 
too tight. (Moullin.) 



3° 



SUTURES, METHODS AND MATERIALS 



through most of its extent (Fig. 19). None is tied until all are 
passed. The lips of the wound are brought together as the knots 
are tied (Fig. 20). 

A few superficial catgut sutures may be necessary if the deep 
sutures do not completely approximate. They are passed through 
the thickness of the skin alone and very close to the edge of the wound 
(Fig. 21). 

No knot should be drawn too tight. It may interrupt the circu- 
lation and defeat repair. The knot should be made to one side of, 
1 and not over the wound (Fig. 22). 
* If all goes well, the sutures may be removed 

toward the eighth day. Remaining too long, 
they favor infection. 

Methods of Removing Sutures. — Seize the loop 
with a dissecting forceps held in the left hand. 
With a pointed scissors divide the thread 
close to the skin, being careful not to cut be- 
tween the knot and the forceps, else one will 
be trying to pull the knot through the skin 

Suppose, in spite of care, infection occurs 

The temperature reaches ioo^° on the follow 

ing day. On the second day following, it is a 

f little higher. Upon removal of the dressing, 

„. the skin around the wound is found to be 

Fig. 24. 

The subcuticular suture; reddened and swollen. Remove two or three 
method of passing and of the middle sutures at once. Secure drain- 
age and use a wet dressing. This will usually 
check the infective process and pus formation. 

The subcuticular suture is of great service in aseptic operative 
wounds, wherever it is especially desired to prevent a scar. It is 
made in this manner: 

Introduce a small needle threaded with No. 1 catgut, J4 
inch above the upper angle of the wound, and let it penetrate the 
skin and emerge exactly at the upper angle. It next penetrates 
the face of the skin incision, taking a bite first on^one side and then 
on the other exactly opposite (Fig. 23). At the end, the needle 
traverses the skin at the lower angle of the wound in the same 




: 



THE SUBCUTICULAR SUTURE 3 1 

manner as it entered at the upper angle; the sutures are then 
tightened (Fig. 24) until the edges of the wound are exactly coapted. 
The ends are secured from slipping either by knotting or by pasting 
them down with collodion or adhesive plaster. If the thread is not 
absorbed, it may be removed about the sixth day by clipping one 
end close to the skin and then gently drawing it from the other 
end. 

Cannaday uses pagenstecher linen and after starting the suture 
secures the loose end by a half bow knot. The terminal thread is 
secured in the same way and slipping or loosening is thus prevented. 



e 



CHAPTER V 
DRAINAGE 

Drainage may justly be regarded as a matter of antisepsis. It 
prevents sepsis by creating a current which moves away from the 
wound, and by depriving the bacteria of their chief pabulum — the 
wound exudates. Drainage facilitates repair by relieving tension 
In the same manner it relieves pain. But when these points ar 
made the whole is said, for drainage is by no means an unmixed 
good. On the contrary, it is a necessary evil and for these reasons: 
in reality it is a foreign body; it necessitates frequent renewal of 
dressings; it may injure granulations; it keeps the wound open and 
delays healing; in the abdominal cavity it sometimes predisposes to 
fistula, hernia, and intestinal obstruction. Nor is the profession by 
any means of one mind regarding the indications and contra-in- 
dications. It is a matter in which one cannot be dogmatic. The 
rule of practice must of necessity vary with the patient, the 
operator, and the environment. 

The emergency surgeon, the general practitioner, will more often 
drain than the hospital surgeon in formal operations. And this 
leads to the fundamental principles involved. 

Aseptic wounds, as a rule, do not require drainage. 

Infected wounds or those suspected should always be drained, for 
infection of any kind demands an outlet. 

Accidental wounds are presumed to be infected, whereas operative 
wounds are presumed to be aseptic. 

As an exception to the rule that aseptic wounds do not require 
drainage, note that those in which there is of necessity much post- 
operative oozing do better with temporary drainage. Examples: 
large amputation stumps, and breast amputations. 

Suspected wounds are not drained after the third day, if infection 
has not made its appearance nor seems likely to develop. 

Infections are drained as long as there are any discharges. 

32 



WICK AND CIGARETTE DRAINS 33 

The means of drainage in emergency practice are three: tubes, 
gauze, and open wounds; or combinations of the three. 

Rubber tubes, the larger the better in proportion to the infected 
cavity, are the best means of draining large cavities, and are the 
sole means of draining abscess cavities and large infections. They 
should be fenestrated, and may be improvised from rubber catheters. 
Wherever used, they must be cut off close to the surface and, in the 
case of cavities, must be anchored by suture or safety pins. 

Gauze. — Plain sterile gauze, which drains by capillarity, is an 
efficient means of removing exudates, such as serum and blood. It 
has the additional advantage that in appropriate cases it may be at 
the same time employed for hemostasis. It has the disadvantage 
that it soon ceases to drain, acquires adhesions, and is painful to 
remove. 

Tubal and capillary drainage are advantageously combined in the 
" gauze wick" and " cigarette drain." A " gauze wick" drain is 
made by splitting a tube of the required length and fitting it loosely 
with a strip of gauze. When the tube is carried to the bottom of the 
cavity, the projecting gauze is brought in contact with the oozing 
surface, is hemostatic, and finally may be removed without dis- 
turbing the tube. A cigarette drain acts on the same principle and 
is essentially a series of wick drains, one within the other. To make 
a " cigarette drain," take a io-inch square of rubber tissue, cover 
it with four or five layers of sterile gauze, and roll the whole into a 
slender cylinder. 

" Wick" and " cigarette" drains should be removed on the second 
or third day. If infection is present at that time, a tube should be 
substituted; a tube must be employed if infection develops later. 
Tubes employed in the drainage of pus cavities should be removed, 
cleaned, and reinserted at least every third day, and are to be 
shortened pari passu with granular repair. 

As has been said, an open wound is a means of drainage, and for 
that reason accidental incised wounds are, as a rule, not completely 
sutured. Lacerated wounds not repairable need no other drainage 
than that afforded by the gauze dressings. 

To note briefly some examples of drainage: Abscesses are always 
to be drained with tubes. 
3 



34 DRAINAGE 

Acute spreading infections are to be drained with tubes. 

Accidental incised wounds are to be drained with tubes, or simply 
by rubber tissue if the wound is small. 

Operative wounds of the soft parts in emergency practice are often 
best drained superficially — all the layers are completely closed ex- 
cept the skin. A few strands of catgut between the lips of the 
wound will often be all that is necessary for drainage and has the 
advantage of requiring no change of dressing. 

An empyema or purulent peritonitis must be drained with tubes. 

Many thoracic and abdominal conditions are to be drained with 
the wick or cigarette drain. If there is no probability of infection, 
if there is not much oozing, do not drain at all. 

In compound fractures and compound dislocations drain only the 
skin wound. If infection develops, deep drainage must be substi- 
tuted. 

Further details will be given in connection with the various 
operations requiring drainage. 



CHAPTER VI 

DRESSINGS, BANDAGES, SPLINTS 

The emergency surgeon needs no great variety of dressing materials. 
If he has sterile gauze and sterile absorbent cotton, he can efficiently 
meet all the indications so far as dressings are concerned; for these 
materials furnish in the highest degree the properties which pertain 
to a good dressing. A good dressing is sterile, absorbent, and pro- 
tective. It conducts the exudates away from the wound and 
prevents the approach of infective germs. For emergency work 
it is better to buy these materials already prepared and ready for 
instant use. But they must come from a reliable source. Even the 
most trustworthy products are not always aseptic. In major opera- 
tions they should be re-sterilized if possible. Of course the surest 
way to sterilize is by steam. Still these materials exposed to the 
high heat in the closed oven of the kitchen stove might reasonably 
be expected to be germ free. Medicated gauze is often useful but not 
essential, nor so much employed as formerly. It may be improvised 
by dusting the plain sterile gauze with the preferred antiseptic 
powder at the time of dressing. For that matter all of the dressing 
may be improvised for temporary use from muslin, linen, or cheese- 
cloth. Towels or sheets may be prepared by boiling for fifteen 
minutes in soda solution, rinsing in cold sterile water, wringing out 
the water, and completing the drying process on the stove. From 
these materials one may provide not only dressings, but compresses 
and sponges for the operation. 

An aseptic wound requires that the dressing be dry; whatever slight 
serous oozing there may be is thus rapidly absorbed. 

Septic wounds require a dressing moist with some antiseptic solu- 
tion. For one thing, the moist gauze conforms better to the irre- 
gluarities of a lacerated wound. Again, the antiseptic agent exerts 
some slight destructive effect, perhaps, upon the germ already in the 

35 



36 DRESSINGS, BANDAGES, SPLINTS 

wound and is a more effective screen against those trying to get in. 
Moist boracic and bichloride gauze are the most commonly used. 
If acute sepsis is present, sterile gauze saturated with peroxide 
of hydrogen is to be recommended. As an antiseptic dressing New- 
man particularly recommends gauze saturated with subgallate of 
bismuth. (Lancet, June 28, 1913.) 

The dressings must be ample. Too often an aseptic operative 
wound eventually becomes infected merely because not sufficiently 
protected. The dressings must not only be thick enough, but they 
must extend widely beyond the limits of the wound. It is a poor 
dressing, indeed, if one can lift its edges and inspect the wound. 

The frequency of redressing is variable. In general, the fewer 
dressings the better. The aseptic operative wound should need 
but two dressings. The original dressing is removed when the 
sutures are taken out on the eighth to the tenth day. 

The septic wound may need to be dressed daily. A wound prob- 
ably infected but not septic, one in which a drainage tube was used, 
will need to be dressed on the second to the fifth day, when the 
drainage tube is removed. The frequency of dressing thereafter 
will depend upon the degree of sepsis. In changing the dressing of a 
sterile wound, every precaution must be taken against infection. 
Many a fine operative result is spoiled by carelessness in changing 
the dressing. The hands, the solutions, the instruments, must be 
prepared. 

It is good practice in the case of any kind of wound to change the 
dressing whenever soiled, for sterile exudates may become good cul- 
ture media. One may, however, follow Senn's suggestion, dusting 
the saturated area with boro-salicylic acid or other antiseptic powder 
and covering with an additional layer of cotton and bandage. 

Pain or rise of temperature after the first twenty-four hours is 
always an indication to change the dressing and inspect the wound. 
A loosened dressing calls for renewal. The dressing that slips or 
rubs is a very poor one. When the dressings are adherent to the 
wound surface, they are to be saturated with warm sterile water or 
with peroxide of hydrogen. The latter is excellent when the dressing 
contains dried blood. When changing the dressings any undue 
movement of the parts must be avoided. The principles of support 



THE ROLLER BANDAGE 



37 



and functional rest are not to be neglected even for the short time 

BANDAGES 



the dressing is off. 



The gauze roller is porous, absorbent, protective, and therefore 
a part of the dressing. The wound is covered with gauze, the gauze 
is amply covered with absorbent cotton, and the whole retained by a 
smooth bandage, uniformly compressive. Bandaging, as the older 
doctors knew it, is almost a lost art, for the gauze roller is accommo- 




Fig. 25. — Double spicae of groin. (Heath.) 

dating and adhesive plaster convenient. One may give a dressing 
the appearance of stability without its being in reality efficient. The 
bandage must be so applied that it will not slip and will remain 
closed at either end. It must extend well beyond the limits of the 
subjacent dressing, and in the case of the limbs must reach beyond 
the next joint above. For example: a dressing of the foot must 
extend above the ankle; of the leg, above the knee; of the forearm, 
above the elbow. In the region of the groin a double spica should 
be employed, extending well up over the abdomen, and down over 
the thighs (Fig. 25). 



38 DRESSINGS, BANDAGES, SPLINTS 

A bandage of the neck, that it may not slip, must include the head 
and shoulder. 

The dressings of the abdomen and thorax are best held in 
place by wide bands of flannel firmly applied and secured by 
safety pins, and whose edges are held down by suspenders and 
perineal strips. 

To apply a bandage to a limb, for example: stand in front of the 
patient. That the bandage may unroll more freely, place the free 
end of the bandage in contact with the dressing by its outer surface, 
and hold the roller to the outside of the limb — in the right hand for 
the left limb, in the left hand for the right limb. Each turn should 
overlap about one-half the previous turn. To maintain uniform 
pressure in spite of the limb's change in contour as the bandage 
progresses certain modifications of the ordinary spiral or circular 
turns are necessary — the " spiral reverse" and " figure-of-eight" 
are to be employed. The " spiral reverse" is used where the cir- 
cumference rapidly changes, as in approaching the calf of the leg; 
if it is not made, one edge of the bandage is tight and the other edge 
loose. To make the reverse, the bandage is slackened when the 
outer side of the limb is reached and a half rotation is made, by a 
twist of the wrist. The beginner is often observed to make a com- 
plete turn of the bandage instead of a half turn. This tightens the 
bandage, but does not give uniform compression. In making the 
turn, the thumb of one hand steadies the lower edge of the bandage, 
while the other hand makes the half turn mentioned. The reverse 
should always be made in the same vertical line and should, if 
practical, correspond to the wound, in order to give it the ad- 
vantage of the extra thicknesses. The bandage is then continued 
on around the leg until the outside is again reached when the 
reverse is repeated. The "figure-of-eight," the second means of 
taking up the slack, is most useful in the region of the joints, and 
at the calf. 

Bandage for the Foot. — (Fig. 26.) Begin near the toes with spiral 
turns, reversed as the ankle is neared. Encircle the ankle with the 
" figure-of-eight " turns and continue the spiral turns up the leg. 
If it is desired to cover the heel, the first turn should cross the upper 
part of the heel and over the front of the joint; the second turn 



BANDAGE FOR THE FOOT 



39 



overlaps the lower half of the first; the third turn overlaps the 
upper half of the first. The roller on the third turn reaches the 




Fig. 26. — Bandage of foot. (Heath.) 



Fig. 27. — Bandage of foot. Heel covered. 
(Heath.) 



dorsum of the foot, and is carried obliquely across toward the little 
toe and the foot is covered by spiral turns which progress upward, or 
it may be applied as indicated in Fig. 27. The spica of the foot is 




Fig. 28. — Spica of foot. (Stewart.) 

indicated by Fig. 28. If it is desired to cover the toes, back and forth 
folds extending from in front of the ankle to a corresponding point 



4Q 



DRESSINGS, BANDAGES, SPLINTS 




Fig. 29. Fig. 30. 

Bandage of leg. (Heath.) 




Fig. 31.— Figure of "8" of knee. 
(Heath.) 




Fig. 32.— Bandage of knee. 
Spiral reverse. (Heath.) 






BANDAGE FOR THE LEG AND KNEE 



41 



on the sole may be run on and held in place by additional circular 
turns about the foot. 

Bandage for the Leg. — Begin above the ankle with spiral turns, 
progress upward and, as the calf is approached, use the reverse 
(Fig. 29); or a " figure-of-eight" may be employed throughout 
(Fig. 30), but the latter does not fit so well about the calf as the 
former. 

Bandage for the Knee. — This may be a continuation of the leg 
bandage or may include the knee alone; in either case it is a "figure- 
of-eight? running from below the patella around the outer side of 




Fig. 33- — Spica of groin. {Heath.) 



the knee, across and up behind the knee to the inner condyle. Now 
make circular turns about the thigh. From the inner condyle, 
cross the knee obliquely downward and outward to the head of the 
fibula; make a circular turn about the leg below the knee, and, when 
the patellar line is reached, begin over again the " figure-of-eight/ ' 
lapping the preceding one (Figs. 31, 32). 

Bandage for the Groin. — Begin at the inner end of the groin and 
f<^rry the roller upward and outward to the iliac crest, around to the 



42 



DRESSINGS, BANDAGES, SPLINTS 




Fig. 34.— Bandage for breast. {Heath.) 




Fig. 35. — Bandage Jor both breasts {Heath.) 






DOUBLE SPICA FOR GROIN 



43 



opposite crest, obliquely across the belly toward the pubes, around 
the thigh to the starting-point. Repeat these turns as often as 
necessary, each overlapping the preceding (Fig. 33). 





Fig. 36. — Finger bandage. 
{Heath.) 



Fig. 37. — Spica of the thumb. 
(Heath.) 



The Double Spica. — The right groin is bandaged as described 
ove. When the roller, carried about the body, reaches the left 
side of the pelvis, it leaves the original track, follows the left groin 




Fig. 38. — Bandage for all the fingers. (Heath.) 

[own ward and thence around the thigh; is then carried across the 
belly and around the body to the right groin again. These band- 
ages may be applied with the patient standing or with the pelvis 



44 



DRESSINGS, BANDAGES, SPLINTS 



on the Volkman rest. For the perineum and pelvis, one may use 
the " St. Andrew's cross," which, after a turn about the body, crosses 
over the left groin, behind the left thigh just below the nates, ob- 
liquely upward across the perineum, over the right groin toward 
the right iliac spine. It then passes around the left iliac spine and 
down the left groin across the perineum. 

Bandage for the Breast. — Begin with two or three turns about the 
chest; carry the roller across the breast to the sound side; next 




Fig. 39- — Bandage for arm. {Heath.) 



carry it under the affected breast to the opposite shoulder; across 
the back to the breast again and up over the shoulder; and then 
around the body again (Fig. 34). Both breasts may be bandaged 
at the same time, carrying the turns about first one breast and then 
the other (Fig. 35). - 

Bandage for the Finger. — -Begin with two or three turns about the 
wrist, and then carry the bandage across the dorsum of the hand 
and base of finger, and run it down to the tip by two or three oblique 
turns; bandage from the tip to the base by regular circular turns. 



SPICA FOR THE SHOULDER 



45 



From the base, carry the bandage across the dorsum of the hand 
and around the wrist again (Fig. 36). 

Bandage for the Thumb. — Begin at the ulnar side of the wrist and 
carry the bandage across the dorsum around the wrist for a turn or 
two. Next carry the roller obliquely across the dorsum of the 
hand and toward the radial side of the thumb, as near the tip as 
desired. Secure by a circular turn and then carry the roller back 
to, and around, the wrist again and so proceed, progressing toward 
the base of the thumb (Fig. 37). Bandage for all the fingers and 
thumb, see Fig. 38. 





Fig. 40. — Spica for shoulder. 
{Heath.) 



Fig. 41. — Bandage for 
head. {Stewart.) 



Fig. 42. — Barton's 

bandage. {Gould's 

Illust. Diet.) 



Bandage for the Hand and Arm. — Begin with circular turns around 
the wrist and then carry a "figure-of-eight" about the wrist and hand; 
finish with spiral turns progressing up the arm (Fig. 39). 

Spica for the Shoulder. — Begin on the arm about the insertion of 

! the deltoid and make two or three circular turns about the arm. 

J ^Next carry the roller across the shoulder, approaching the sound 

a axilla from behind; across under the axilla and over the breast to 

the injured shoulder and around the arm again (Fig. 38). 
e Bandage for the Neck. — The shoulder and head must be included 
i in the bandage for the neck if it is to be effective. Begin on the 
shoulder and carry the roller through the axilla and around the 
ck once or twice. Take the turn next about the neck and beneath 



r 



46 



DRESSINGS, BANDAGES, SPLINTS 




Fig. 43. — Capitellum. (Heath.) 




Fig. 44.^-Capitellum completed. (Heath.) 



BANDAGE FOR THE EYE 



47 



the jaw, behind the ear on the sound side, over the top of the head, 
down in front of the ear on the affected side. Next carry the 
roller horizontally around the neck and then beneath the jaw once 
more; again vertically around the head; but this time it passes in 
front of the ear on the sound side and behind the ear on the affected 
side. Carry the roller now a third time beneath the jaw and, finally, 
from the occiput around the forehead to fix the other turns. 

Bandage for the Head. — A dressing may be secured in many in- 
stances by simple turns about the forehead and occiput; but the 





Fig. 45. — Showing manner in which 
eye is covered and the ear engaged in 
one slit in the bandage and the occiput 
in the other. 



Fig. 46. — Showing sound eye free 
and manner of tying together the two 
ends of the bandage on the sound side. 



bandage may be made to hold firmer if, as it approaches a certain 
point, it is raised in one turn and lowered in the next. It has the 
appearance of a spiral reverse (Fig. 41). 

Barton's bandage may be used (Fig. 42). Begin at the top of 
the head, carry the roller beneath the chin, up to the vertex, across 
and to a point below the occiput. From this point, carry it forward 
to the chin and on to the occiput. Bring it up to the top of the 
head and again beneath the chin and proceed as in the beginning. 

Figs. 43 and 44 represent one method of applying the recurrent 
,or capitellum to the head. 

Morley describes a useful and practical bandage for the eye 
j (J. A. M. A., Mch. 27, 1909). Take a piece of muslin, or gauze, 




48 DRESSINGS, BANDAGES, SPLINTS 

long enough to go about the head and wide enough to cover the 
orbital region. At its center cut a round hole for the ear of the 
affected side and further back an oblong slit for the occiput. Trim 
the bandage so as to uncover the sound eye. Split the two ends 
and tie these tails tight enough to prevent slipping (Figs. 45, 46). 

The crossed bandage for both eyes is a figure-of- 
eight with circular turns about the head (Fig. 47). 
Bandage for a Stump. Begin with circular 
spiral turns some distance up the limb. Carry 
the bandage back and forth over the end of the 
stump, and finish by more circular turns. 

SPLINTS 

fig. 47.— Bandage for To immobilize, to prevent muscular contraction, 

both eyes. (Heath.) ' - . , ,. , , 

or to secure tunctional rest, splints play a large 
part in surgical practice. The emergency surgeon must be fami- 
liar with the principles regulating their employment and with the 
practical details of their use. A splint must have rigidity; it should 
be light. A number of materials offer these properties in varying 
degrees, though none are ideal perhaps, or universally applicable — • 
wood, metal, leather, wire, cardboard, felt, plaster of Paris, silicate 
of potash — each has its special field of usefulness. More especially 
employed in emergency practice are wood, metal, and plaster. 

Wooden Splints. — Wood is the material usually most available 
when temporary splints must be improvised. Often these splints 
may be used for permanent fixation, though not so much so perhaps 
as formerly. From soft wood — -a thin pine wood — -the appropriate 
form may be readily whittled; and, when applied, well wrapped 
so as to conform to the parts, furnishes a fixation at once light and 
rigid. The splint must be wider than the limb and long as the part 
to be immobilized, but not so long as to produce discomfort. The 
sound limb may be used as a pattern in modeling the splint. Such 
splints have the disadvantage that they are hard to keep in place. 
A number of thin wooden strips may be glued to felt, ,or held to- ; 
gether by adhesive plaster, to form effective fixation in certain' 
fractures of the humerus and thigh. On this principle the Dutch I 



PLASTER OF PARIS 49 

cane splints are constructed for use in the emergencies of warfare. 
Gooch's splint is made from a pine board 2 feet long and 6 or 8 inches 
wide and y± inch thick, pasted on to felt and then split in strips H 
inch wide. Before the ordinary wooden splint is applied, it should 
be padded with absorbent cotton 2 to 4 inches thick and wrapped 
with a gauze roller. The cotton should be distributed to corre- 
spond to the irregularities of the limb. The splint is molded to 
the limb, and held in place with adhesive strips while the roller 
bandage is applied. 

Metal splints as ordinarily employed are scarcely available in 
emergency practice. These materials cannot, as a rule, be readily 
worked into shape; but, on the other hand, if ready-made, are 
likely not to fit. However, in case of necessity, a splint could be 
cut from tin or from wire gauze. Wire gauze, indeed, forms part 
of the outfit of the military emergency bag. It can be patterned, 
molded and bandaged to the part; the cut edges should be turned 
over or covered with cloth. 

Plaster. — -Plaster of Paris, on the whole, is the material best 
adapted to the exigencies of emergency practice. It is not too bulky, 
cheap, easily obtained, and readily prepared; once applied, it is 
not unduly heavy and furnishes a firm support. It has the special 
advantage that it can be molded to the part; the disadvantage, that 
it may be difficult to remove when applied as a roller bandage. 
Plaster is spoiled by exposure. One should buy a good quality and 
keep it dry. Old plaster should be baked before using. Plaster 
may be applied on a roller bandage or on strips to make a molded 
splint. The splint form is better when the parts must be frequently 
inspected or when much swelling is anticipated. The plaster 
roller may be prepared from the ordinary gauze roller or from crino- 
line. The latter is perhaps the best. The rollers should be about 
4 yards in length; 2, 3, and 5M inches in width. To prepare the 
plaster bandage, pour the plaster on a table or in a wide shallow basin. 
Start the loose end of the roller through the plaster, rubbing it in 
thoroughly, and as fast as it is impregnated have the assistant re- 
roll it (Fig. 48). These bandages will keep indefinitely in an air- 
tight container. Prepared in this way they are much more satis- 



So 



DRESSINGS, BANDAGES, SPLINTS 



factory than if bought ready-made — -and certainly much less 
expensive. 

[Method of Applying, — When the limb is ready, washed, and 
covered with glazed cotton or stockinet, the plaster roller is set in 
a pan of warm water deep enough to cover it. When the bubbles 
cease to rise, it is ready to apply. Seizing it at each end, wring it 
gently. Begin by making a few oblique turns at first to secure the 
dressing or cotton, and then cover the limb by systematic circular 
turns, progressing from below upward, each turn overlapping the 
preceding one. The " reverse" must not be used. A little loose 
plaster may be spread on and moistened to give a smooth and even 
finish. The limb must be supported and the extension maintained 




Fig. 48. — Method of rolling plaster bandage. 

until the plaster has hardened. A little salt added to the water 
hastens the process. If there is danger of swelling, or if the limb 
cannot be frequently inspected, it is better to split the case before 
leaving the patient. Sometimes it is quite a task to split a plaster 
cast after it is thoroughly hardened. The labor may be greatly 
lessened by the use of simple syrup, a groove being first cut with 
plaster knife or saw; if the groove is kept filled with syrup while 
the cutting is in progress, one will get through the plaster rapidly. 

Plaster splints are made by cutting several thicknesses of crino- 
line, appropriate to the shape of the limb. It is saturated with 
plaster, each layer separately, dipped in warm water until well 
soaked, then applied and molded to the limb. Fix it with circular 
turns of a muslin bandage. The second splint, if needed, is then 
applied and fixed by a second series of circular turns. The splints 



PLASTER OF PARIS SPLINTS 5 1 

may be fixed by a plaster roller if desired. A still better way is to 
fold the crinoline into the desired number of layers and cut them 
all at once from the pattern determined. Warm water and a basin 
are next provided and plaster is slowly sifted into the water, until 
it ceases to bubble; when it is mixed, until it has the consistency of 
cream. The cloth is then dipped in and saturated. When well 
soaked, the excess of plaster is pressed out and the splint is ready to 
apply. 

The Bavarian plaster splint is particularly useful in immobilizing 
the leg. Cut two pieces of flannel long enough to extend from the 
upper end of the thigh under the heel to the ball of the toes, a few 
inches wider than the greatest girth of the limb. Stitch these 
pieces together along the middle line for the length of the leg. Put 
the splint thus formed under the limb, with the seam exactly in the 
middle; bring the inner half around, fitting it to the leg, the dorsum 
and sole of the foot, like a stocking. Smear this stocking with 
liquid plaster and, before it sets, turn the outer half over the plaster 
and mold it and adjust the end pieces to the sole. The splint can 
be easily removed, as the seam along the back acts as a perfect 
hinge. 



CHAPTER VII 

SHOCK 

Shock is a constitutional state characterized by lowered blood pres- 
sure, due to vaso-motor paralysis. 

In practice, the term " shock" includes the complex of symptoms 
arising from the vaso-motor paralysis, hemorrhage, mechanical in- 
terferences with circulation and respiration, and beginning infection. 

It may not be possible to analyze the symptoms, determining the 
part played by each of these various conditions in a given case, nor 
is it necessary to do so. 

Nevertheless, the proper understanding of shock as a separate 
entity is essential in emergency surgery next to skill in hemostasis. 

Peripheral impulses reach the automatic centers controlling blood 
pressure and overwhelm them. Such is the commonly accepted 
view of shock production. 

Lucy Waite, after reviewing the subject from every standpoint, 
concludes that, according to our present light, we must consider it 
primarily a disturbance of the great sympathetic nervous system; 
secondarily, the vascular system, resulting in vaso-motor paresis 
and dilatation of the right side of the heart and the large vessels; 
in natural sequence derangement of the solar plexus and the auto- 
matic visceral ganglia follows; finally there is suppression of visceral 
activity — of rhythm, absorption, and secretion. (Medical Record, 
Sept. 8, 1906.) 

This is practically in accord with the results of recent experi- 
ments of Janeway and Ewing. "The loss of vaso-motor control 
is never due to ocopnia or central nervous exhaustion in their 
opinion but is rather a matter of inhibition. (Annals Surgery, 
Feb., 1914.) 

The symptoms of shock vary in degree with its severity and are 
chiefly incident to the lowered blood pressure: thirst, pallor, subnor- 

52 






DIAGNOSIS OF SHOCK 53 

mal temperature, shallow breathing, frequent sighing or yawning, 
rapid pulse, relaxed sphincters, faintness, nausea or vomiting, and 
unconsciousness. 

These may appear in their slightest manifestations, or in such 
forms as usher in death. As Waite says, syncope causing always a 
cerebral anemia is practically identical with the last manifestations 
of overwhelming shock. 

Whether shock will be mild, severe, or fatal depends upon the 
state of the individual, the character and continuance of trauma, 
the means of injury, and the tissues wounded. Age, sex, general 
health, and mental state are factors to be taken into consideration. 

Crushing injuries with mangled nerves sending their constant sig- 
nals to the disturbed vaso-motor centers furnish conditions favorable 
to fatal shock. Railroad accidents are typical of such as produce 
the severest symptoms of shock, for fright and violent emotions 
even without injury may be followed by vaso-motor paralysis. 

Certain tissues resent insult more than others. Those which line 
the body cavities are most sensitive with respect to injury; the 
peritoneum, the pleura, the dura, and the synovial membranes 
of the large joints. This is true whether the trauma be accidental 
or operative. 

The diagnosis of shock as distinct from hemorrhage and collapse 
cannot always be made with certainty. As Waite says, the diag- 
nosis of shock is simply the recognition of the clinical phenomena, 
for we have no chemical or pathological findings to aid us. 

In many instances it may be differentiated from collapse by the 
history of the case. 

In collapse the heart action is slow and feeble, whereas in shock 
it is rapid and feeble. 

In hemorrhage the symptoms may be rapidly progressive, but in 
uncomplicated shock the symptoms are stationary or improve. 
Observe, therefore, the action of the pulse and the movement of 
the temperature. In hemorrhage the temperature falls and the 
pulse rate increases. In shock the pulse becomes gradually slower; 
the temperature gradually rises. 

The prognosis in the severe cases will be for a little time decidedly 
uncertain. The sufferer from traumatic shock may give the doctor 



54 SHOCK 



ion 



an erroneous notion of the gravity of the case, unless the condition 
of the pulse is carefully noted; for he may complain of no pain, is 
cheerful in the face of his calamity, discusses the need of operative 
measures quite coolly and directs the management of his case generally. 
He seems quite rational, and yet it often happens that after recovery 
he has no recollection of what he said or did or felt. It is prob- 
able, in the presence of grave injury that, if the pulse is thready and 
still failing, the patient does not know what he is talking about, how- 
ever lucid his expression may appear. A little later he may be in 
active delirium. Any increase, not too lonj delayed, in the blood 
pressure and the attendant improvement, is a cause for hope. It 
may take many hours before the reaction is complete. 

Any aggravation of the symptoms after reaction is once under way 
never indicates a return of the shock, but points to hemorrhage or 
infection. 

It is true that, as a rule, when once improvement begins the out- 
look is favorable, but the prognosis must always be guarded in the 
case of the elderly. 

An old flagman was brought to the City Hospital with both limbs 
crushed off, having fallen under a passing engine. He was in full 
shock and had lost some blood from a scalp wound. He was almost 
pulseless and yet his mind seemed clear. His condition precluded 
operation. The mangled tissues were trimmed and carefully 
cleansed and wrapped in moist antiseptic compress until such time 
as formal amputation might be undertaken. Under the treatment 
for shock he gradually improved. His circulation and respiration 
grew stronger, but not sufficiently so as to favor operation. At the 
end of twenty-four hours he began all at once to grow weaker, fell 
into a stupor, and in a few hours died. If the amputation had been 
undertaken, he would have died on the table, and thus another fa- 
tality would have been charged to active intervention. 

The treatment of shock has been the subject of much discussion in 
recent years. The most diverse opinions exist and the most diverse 
methods have been proposed, but we have learned from the ex- 
perience of Crile and others that it is as important to know what not 
to do as what to do. 

The whole list of cardiac and spinal stimulants so commonly in- 






i 



TREATMENT OF SHOCK 55 

jected hastily, indiscriminately and collectively, are shown to be 
not only useless, but distinctly harmful. The patient doubtless 
often recovers not on account of, but in spite, of, such treatment. 

In ordinary cases, these directions are sufficient to be borne in 
mind: disturb the patient as little as possible; lower the head; keep 
the body warm; attempt no operative measures until the symptoms 
are improved, unless it be to check hemorrhage, or to amputate in 
certain crushing injuries. 

Adrenalin chloride is the most generally useful remedy to raise 
blood pressure in shock pure and simple, and given hypodermically 
or intravenously, it very seldom completely fails. 

Crile was enabled by means of intravenous infusion of adrenalin 
and salt solution, combined with artificial respiration and thoracic 
pressure, to arouse a human heart after it had ceased to beat for nine 
minutes, and its action was thus sustained for one-half hour. 

It must be given in small doses, frequently repeated. The effects 
are powerful, but fleeting. 

Hypodermically, give 5 to 15 minims of the 1-1000 adrenalin solu- 
tion and repeat every twenty or thirty minutes. 

Intravenous infusion is even more satisfactory and certain. 
Give continuous infusion of adrenalin salt solution until there are 
signs of reaction. One teaspoonful of i-iooo adrenalin added to 
one quart of normal salt solution is of sufficient strength. 

Normal salt solution alone is effective within certain limits, but 
finds its greatest field of usefulness in shock coexistent with hemor- 
rhage. In shock uncomplicated by extensive loss of blood, the saline 
solution must be used sparingly, perhaps better by enema or hypo- 
dermoclysis; used in large quantities intravenously, it may eventually 
defeat the end for which it is employed by acting as a mechanical 
obstruction to respiration. For it must be remembered that under 
such circumstances it finds its way into the thoracic and abdominal 
tissues and interferes with the movements of the diaphragm and 
ribs by its mere presence. According to Crile, 320 c.c. per kilo of 
body weight led to such accumulation of fluid in the splanchnic area 
as to embarrass respiration. 

Do not give, then, more than a pint of normal salt solution in- 
jected slowly, in uncomplicated shock. (For technic of intravenous 



56 SHOCK 

infusion, see page 59). Murphy uses sodium bicarbonate 1 dram 
to iH pints of hot water as a proctoclysis, repeating the dose every 
three to five hours. 

Crile's pneumatic suit seems to be entirely trustworthy as a means 
of raising blood pressure; but, of course, cannot be used in th 
shock occurring in emergency practice. 

The prevention of shock is always something to be considered in 
operative work. Morphine, 34 grain hypodermically, before the 
anesthesia, is a real aid. " Blocking" the nerves by cocaine in 
jections above the site of operation is likewise advantageous and i 
recommended by Cushing and Crile. The nerve may be exposed 
in its course under local anesthesia and in turn injected. 

In abdominal work the viscera must be handled with care; for, a 
Byron Robinson has shown, shock from this source is directly pro 
portionate to the amount of manipulation or traction upon th 
viscera. 






CHAPTER VIII 
HEMORRHAGE 

Definitions. — i. Arterial hemorrhage is due to wounds of arteries 
and is characterized by spurting and the bright red color. 

2. Venous hemorrhage is due to wounds of the veins and is char- 
acterized by dark color and steady flow. 

3. Capillary hemorrhage is characterized by persistent oozing 
and spontaneous arrest. 

4. Parenchymatous hemorrhage is due to wounds of those organs 
and tissues in which the small arteries terminate directly in veins; 
no capillaries intervening, as in the erectile tissues. 

5. Primary hemorrhage occurs immediately after the injury. 

6. Intermediate or reactionary hemorrhage occurs within twenty- 
four hours and is due to the release of clots or the slipping of the 
ligature. 

7. Secondary hemorrhage occurs after twenty-four hours, before 
the cicatrization of the wound, and is usually due to sloughing or 
suppuration or the too rapid absorption of the catgut ligature. 

8. Internal or concealed hemorrhage occurs when the blood is 
. emptied into one of the large cavities; abdomen, thorax or cranium. 

CONSTITUTIONAL EFFECTS OF HEMORRHAGE 

The constitutional effects of hemorrhage vary with the amount 
and the rapidity of the loss of blood. Thus a comparatively small 
amount of blood poured out rapidly will produce more marked 
symptoms than a much larger amount drained away slowly. 

The constant accompaniments of severe hemorrhage are pallor, 
dizziness and faintness, rapid and weak pulse, subnormal tem- 
perature, rapid and irregular breathing, frequent yawning or sigh- 
ing, nausea, and vomiting. 

57 



; 



58 HEMORRHAGE 

Fatal hemorrhage, or one likely to be so, is indicated by livid lips, 
blue finger nails, dilated nostrils, pallid mucous membranes, dyspnea, 
ringing in the ears, syncope, collapse and unconsciousness. 

Subsequent to the arrest of a dangerous hemorrhage, occur rapid and 
irregular pulse, rise of temperature, asthenia, a disturbed mental 
condition, usually muttering delirium. This is hemorrhagic fever. 
As the general condition improves, the mind gradually clears up. 
The lowered vitality following the hemorrhage favors the develop- 
ment of various inflammatory processes, and one must carefully 
watch for the onset of these. 

The diagnosis of hemorrhage is not difficult except in the case of 
internal hemorrhage, or when shock is present. 

In the case of bleeding into the cranial cavity, various forms o 
paralysis and nervous disturbances, together with the genera 
symptoms, will form the basis of the diagnosis. 

In the case of bleeding into the thorax and abdomen, the symp- 
toms, the physical signs, and the history of the case will point to the 
condition. (See Injuries to Thorax and Abdomen.) 

When shock is also present it may be almost impossible to tell ho 
much of the symptoms are due to the one or the other, for the symp 
toms of shock and hemorrhage are practically identical. 

It is useful to remember that the symptoms produced by shock ar 
usually immediate and tend to improve, except in the fatal cases 
On the other hand, the symptoms of unchecked hemorrhage tend 

to grow worse. 

* 

TREATMENT OF HEMORRHAGE 

The First Indication is the Arrest of Hemorrhage, Constitutional 
measures are then applied with a view to supporting the heart's 
action. In moderately severe cases give K ounce of whiskey or a 
hypodermic of strychnine (3^o to Mo grain), or of adrenalin chloride, 
and repeat every hour until the symptoms have improved. Apply 
warm blankets, hot water bottles, or hot irons well wrapped. Do 
not burn the patient. Keep him quiet, with head lowered. Attend 
to the ventilation. As soon as possible give warm drinks and a 
nutritious but easily digested diet. Do not overstimulate, as the 
reaction in that case will be unduly severe. 



! 



INTRAVENOUS INFUSION 59 

In the dangerous cases of hemorrhage, in addition to these meas- 
ures, do not fail to employ normal salt solution either by enema, 
subcutaneous injection, or intravenous infusion. 

In the gravest cases, enemas will be of no avail, for absorption has 
practically ceased. 

Hypodermoclysis will be a little better. For this purpose employ: 

1$ — Sodii chloridi., 3 i- 

Sodii bicarb., gr. xv. 

Aq. destilL, 5 xvi. 

The necessary apparatus: a carefully disinfected fountain syringe 
or a funnel with rubber tubing, a large needle (an aspirating needle). 
One-half pint or more of the solution is injected by this means 
under the skin over the abdomen or breasts. 

Intravenous Infusion, — In the gravest cases, the same solution 
by the same means may be injected into the venous circulation. 
Select a vein at the elbow, employ the strictest asepsis, and expose 
the vein by incision. Loosen it from adjacent tissues by careful 
blunt dissection and slip three catgut ligatures under it. Introduce 
the needle, or else the vein may be opened and a cannula used. The 
cannula or needle is to be held in place by tying the middle ligature. 
Slowly inject a pint or more of the solution, the temperature of which 
should be 105 to 115. Withdraw the cannula, remove the middle 
ligature, and tie the two remaining. Close the wound and dress 
aseptically. Keep the funnel full during the injection, so that no 
air may be carried into the vein. 

Crile recommends direct transfusion from the vein of a well person 
into that of the patient, but of course this method is scarcely available 
in emergencies of general practice. 

Parke-Davis & Company market a sterile salt in sterile tubes 
which needs only to be emptied into a liter of sterile water to form a 
solution for instant use. The formula used is as follows: 

Calcium chloride, 0.25 gm. 

Potassium chloride, 0.1 gm. 

Sodium chloride, 9.0 gm. 

Remember that intravenous infusion is not to be employed until 
the hemorrhage is arrested. 



60 HEMORRHAGE 

HEMOSTASIS — ARREST OF HEMORRHAGE; GENERAL PRINCIPLES 

Spontaneous arrest of hemorrhage is due to several factors: con- 
traction and retraction of the injured vessels, diminishing blood 
pressure due to weakening heart action, formation of a clot, these are 
the agents which nature employs. 

Capillary hemorrhage tends to spontaneous arrest, likewise the 
arterial hemorrhage of lacerated wounds. 

Hemostatic measures locally applied are chemical, thermal, and 
mechanical. 

(A) Chemical remedies, chiefly styptics, are now very rarely em- 
ployed. Such as are used are expected to favor the formation of 
a clot without doing violence to the tissues. In a persistent capillary 
hemorrhage, dioxide of hydrogen or acetanilid is often useful and 
harmless, but the most useful remedy locally applied is adrenalin 
chloride. The i-iooo solution is commonly used. 

(B) Thermal hemo stasis is that induced by heat. Hot water or 
hot normal salt solution alone will usually arrest a moderate bleed- 
ing. Use the solution as hot as can be borne by the hand. Hot 
solutions are especially useful since they serve the double purpose of 
antisepsis and hemostasis. The actual cautery may be necessary 
in spongy tissue w r here the oozing is persistent but ill defined. The 
iron should not be hotter than a dull red and must be held in contact 
for some moments. Cold may be used but is much more likely to 
lower cellular vitality. 

(C) Mechanical hemostasis includes (i) direct pressure, (2) com- 
pression, (3) acupressure, (4) forcipressure, (5) torsion, (6) ligation. 

(1) Direct pressure is of large service especially in " first aid" 
treatment. The finger or thumb is pressed directly into the wound, 
or on each edge of the wound. If the pressure is to be prolonged, 
the finger will tire and a plug or tamponade of gauze must be sub- 
stituted. Gauze wrung out of a sterile solution is packed into the 
wound. 

Direct pressure is sufficient in the slight hemorrhage of operative 
wounds. The assistant presses a gauze compress on the bleeding 
surface, withdraws it by a gliding movement, and the bleeding 
practically ceases. 



HEMOSTASIS 6l 

In general, the larger the vessels, the firmer and more prolonged 
must be the pressure. 

In severe hemorrhage, direct pressure, is of course, a mere tem- 
porary expedient. 

Parenchymatous bleeding is checked by direct pressure. The 
wound of the organ is lined with a layer of gauze. In this gauze 
cavity, complete the tamponade. This compress should be with- 
drawn within twenty-four to forty-eight hours. It may be painful 
to pull out. Release a little at a time, or soften the adhesions with 
peroxide. 

2. Compression aims to occlude the vessel above or below the 
wound. In the emergency, a finger is applied to an artery at some 
convenient point along its course at some distance above the 

' wound. Pressure is most effective if the vessel lies closely over bone. 

1 Large veins are similarly compressed below the wound. 

In the case of wounds of the extremities, the main vessels, in- 

1 eluding both the vein and artery or either alone, may be compressed 
by the tourniquet. The pressure is made firmest over the vessel by 
laying over its course a body such as a small roller bandage, before 

1 the constricting band is applied above the wound (Figs. 53, 54). 
The simplest and most convenient tourniquet is a rubber band or 
tube. After being tightened, the crossed ends are caught and held 
in place by an artery forceps. It must always be remembered that 
the tourniquet is likely to cut off all the .blood supply to the ex- 
tremity and if too long applied will produce gangrene. Paralysis 
may follow from pressure on the nerves. Wrap the arm with a towel 
and apply the tourniquet over that. 

Capillary oozing is frequently troublesome after the constriction 
is removed. Constrictionis objectionable on that account. 

3. Acupressure is now seldom used and yet, under certain circum- 
stances, may render great aid. The artery may be deep and retracted 
or imbedded in scar tissue or aponeurosis and cannot be seized by the 
forceps. In such a case a needle passed under the artery and secured 
with a figure-of-eight ligature wound around its protruding ends will 
press the artery between it and the tissues and stop the flow (Fig. 49). 

4. Forcipressure, the control of hemorrhage by seizing the ends 
of the bleeding vessels with forceps, is the expedient most com- 



62 



HEMORRHAGE 



monly employed in operative wounds. In the accidental wounds 
of large arteries, it affords immediate control of the hemorrhage. 
For the small vessels such pressure is sufficient, the forceps remain- 
ing attached for a certain length of time. The end of the vessel 
should be seized with as little other tissue as possible. If it is a 
large vessel it may be cleared by a moment's dissection. 

5. Torsion is added to forcipressure, if that is not sufficient (Fig. 
50). Before removing the forceps, it is given two or three turns on 
its long axis. The inner coats of the artery are ruptured and con- 
tracted, producing the same conditions favorable to hemostasis as 
are found in the artery in lacerated wounds. If the artery is a little 
larger, it is drawn for }/& inch out of its sheath, a second forceps grasps 




Pig. 49. — Acupressure. (Moullin.) 

it higher up and is held stationary, while the lower one twists the 
intervening segment, the purpose being to avoid injury to the sheath 
and the vasovasorum. 

In making torsion, do not pull at the same time, for fear of tearing 
the other tissues instead of twisting the artery. Torsion must not be 
used where the tissues are loose or cellular. 

Torsion is of advantage especially in plastic surgery, for it leaves 
no ligature behind to interfere with repair; but it is not so certain 
as ligation. 

6. Ligation is finally necessary in bleeding from the larger vessels. 
Employ catgut, chromicized or plain. For the largest vessels silk is 
occasionally used. 

Lift the attached forceps so as to create a pedicle around which 
pass the thread and tie the first knot (Fig. 51). 

In tying the second knot, two things are kept in mind; to tie 



HEMOSTASIS 



63 



tight enough that the thread will hold when the forceps is removed, 
and not to include the tip of the forceps in the ligature. The 
forceps is usually removed as soon as the first knot is tied, so that 
one may be assured the suture is not badly placed before completing 
the knots. The first knot is secured by a second if silk is used, and 
by a third if catgut is used. The threads are then cut short, silk 
1 mm. and catgut 2 or 3 mm. Catgut is the preferable ligature 
and a No. 2 is amply strong for an artery the size of the radial. 

Ligation en masse may be employed in parenchymatous hemor- 
rhage, capillary oozing, or bleeding from a deep wound. A catgut 
suture is carried around the bleeding area by a well curved needle, 





Fig. 50. — Torsion. (Veau.) 



Fig. si. — Showing method of tight- 
ening the ligature. (Veau.) 



and all the tissues so included are tied; or, in the case of paren- 
chymatous bleeding from a surface, a catgut suture may be carried 
around the area and subsequently tightened after the manner of 
the purse string. 

HEMOSTASIS IN SPECIAL FORMS OF HEMORRHAGE 



(a) Capillary — pressure, hot water, ice, adrenalin, peroxide, 
acetanilid, alum, ligation en masse. 

(b) Venous — pressure, compression, forcipressure, ligation, re- 
moval of all obstruction to venous flow above the wound. 

(c) Arterial — pressure, compression, forcipressure, torsion, ligation 



6 4 



HEMORRHAGE 



(d) Parenchymatous — -pressure (tamponade), heat, ligation en 
masse. 

(e) Intermediate hemorrhage — -reopen the wound, turn out the clots 
and treat hemorrhage as if it were a primary one. 

(f) Secondary hemorrhage — reopen the wound, turn out clots, and 
apply compresses. If possible catch the ends of the bleeding vessels. 
If the hemorrhage is alarming and it is impossible to control it by 
compresses or forcipressure, apply the tourniquet, in the case of an 
extremity, and ligate the artery in its continuity above the wound. 
If this fails and the artery cannot be tied higher up, amputate. 

















■ T^ a 






mm 




H^HH 


-*' -. 




1 -^^S^W^?.-- H 




r 1 




fc- J,,v 's « Co.Detrott "'^UjHH 



Fig. 52. 

(g) Operative hemorrhage — In spite of artery forceps, the bleedin 
remains to the inexperienced one of the bugbears of operative work 
In many operations it is the chief drawback to rapid work; more 
time is lost in catching and tying bleeding points than in doing the 
actual operation. Oftentimes the field is masked by a general 
oozing, and the procedure must halt until the wound can be packed 
with hot compresses, which will usually be all that is necessary. 
Gentle and momentary pressure with a gauze compress is usually 
all that is necessary in capillary bleeding. 

In operations in the various cavities, as the nose, mouth, rectum, 
in the mastoid operation, etc., the hemorrhage, even if not discon- 
certing, is often very troublesome and some special measures are 
required. Under the circumstances, Parke Davis' adrenalin gauze, 
which is cut in narrow strips, may be packed in the cavity for 
moment and on its removal the operation may proceed (Fig. 52). 






EMERGENCY HEMOSTASIS 65 

FIRST AID IN DANGEROUS HEMORRHAGE 1 

It is rare that the regulated measures for hemotasis can be applied 
first hand in a dangerous hemorrhage. There are certain temporary 
and makeshift but extremely useful procedures which the surgeon 
should keep in mind, if for no other reason than that he may give 
precise and definite instruction to the layman who may have to 
play the part of surgeon for the time being. 

Intelligent first aid is the chief factor in saving life in most cases 
of dangerous hemorrhage both in military and civil practice. Who- 
ever has to meet these emergencies must keep cool. He must re- 
member how to apply three principles of treatment, position, direct 
pressure, compression. 

1. Position. — -In case the upper extremity is wounded: hold the 
arm above the head. If it is the lower extremity: put the patient 
on his back and elevate the limb. If it is the face or scalp: place 
the patient in a sitting position. 

2. Direct Pressure. — The wound is small, the bleeding is dangerous : 
plug the wound directly with the thumb or finger, or press firmly on 
each edge of the wound; or, in any case and better still, if supplied 
with a first aid packet, stuff the wound tightly with gauze and 
bandage firmly. It should be emphasized that a finger must never 
be thrust into a wound except in cases of greatest urgency and 
where other means less likely to cause sepsis are not at hand. 

3. Compression. — The bleeding vessel is recognized and its course 
is familiar: compress it with the fingers at some convenient point 
or, in the case of the extremities, by constricting the limb. 

In lieu of the tourniquet, knot a handkerchief, apply the knot 
over the artery and tie the handkerchief tightly around the limb. 
If it is not tight enough, a stick may be slipped under the hand- 
kerchief and given a few turns, end for end. A suspender, a rope, 
or a wire may, if necessary, be similarly employed. It must be re- 
membered that, on the whole, circular constriction is not without its 
dangers, and it must not be recommended without reserve to the 
layman. 

1 See also "First Aid on Battlefield," page 179. 
5 



66 HEMORRHAGE 

£ The principal arteries near the surface have each certain points 
where compression is most effective. 

The temporal and occipital furnish most of the dangerous bleed- 
ing in scalp wounds. 

The temporal may be compressed just in front of the upper part 
of the ear. 

The occipital may be compressed in its course from the tip of the 
mastoid upward toward the occipital protuberance. 

The entire blood supply of the scalp may be shut off temporarily 
by a bandage encircling the head, passing from the forehead, above 
the ear, to the base of the skull and thence upward, just above the 
other ear, to the forehead again. 

The facial is compressible as it crosses the body of the jaw jus 
in front of the masseter muscle. 

The coronary arteries, supplying the lips, are compressed by seiz- 
ing the lip between the forefinger and thumb. 

The carotids are controlled by compression of the common caroti 
over the transverse process of the sixth cervical vertebra. 

Wounds of the vessels of the neck, however, are of such extreme 
danger, including, as a rule, both arteries and veins, that bleeding 
should be controlled by direct pressure in the wound. Nothin 
can be so well trusted here as the finger. 

The subclavian is compressible against the first rib behind th 
middle of the clavicle. The shoulder is slightly raised to relax th 
cervical fascia and the finger or a padded stick pushed directly dow 
upon the artery behind the clavicle. The circulation of the entir 
upper extremity is thus controlled. 

The brachial is compressible against the middle of the humerus 
or the tourniquet may be applied over any part of the artery 

(Fig. 53). 

The radial and ulnar are not compressible except just above the 
w r rist; and, therefore, bleeding from them must be controlled by 
direct pressure in the wound, or by the tourniquet, or by com- 
pression of the brachial. 

The palmar arches are not directly compressible, but hemorrhage 
from the palm is controlled by grasping firmly a round body as 
billiard ball, an apple, a stone wrapped with gauze, and bandagin 



■ 



: 



EMERGENCY HEMOSTASIS 



6 7 



the hand in this position. If this is not practical, the tourniquet 
may be applied to the forearm, or the brachial compressed. 

The digital arteries are always easily controlled by constriction of 
the finger above the wound. 

The femoral artery is compressible in the middle of the groin 
against the ramus of the pubes, but great pressure is required here 
to control its flow (Fig. 54). It may likewise be compressed lower 




Fig. 53. — Compression of brachial. 
(Moullin.) 



Fig. 54. — Compression of femoral. 
(Moullin.) 



dow T n against the shaft of the femur. The tourniquet is, in this in- 
stance, the safer temporary hemostatic, a compress of some sort 
intervening between it and the artery. 

The popliteal is not compressible. Bleeding must be controlled 
by direct pressure or by compression of the femoral. 

The tibials likewise. They may also be controlled by flexing the 
knee forcibly upon a pad, holding the pad in place by a cross piece 
pressing forcibly against the popliteal space, and in turn held in 
place by a bandage around the flexed leg (see Fig. 133, page 183). 



68 



HEMORRHAGE 



The dorsal and plantar arteries can best be controlled by direct 
pressure or by compressing the tibials and peroneal as they cross 
the ankle. 

The arteries of the surface of the trunk most likely to produce 
dangerous hemorrhage are the internal mammary, the inter costals, 
and the deep epigastric. These can be controlled temporarily only 
I by direct pressure, either with the finger or 

imr gauze packing. The method of compressing 

IH/^)^V /% ^ e intercostal is represented ill Fig. 55 



Fig. 55- — Tamponing the 
intercostal artery. R, ribs; 
A, artery; W, gauze. (Wal- 
shatn.) 



EPISTAXIS 

PI NS^ Epistaxis is a form of hemorrhage often 

^ troublesome and requiring special treatment. 

It may occur in one or both nostrils. The 
simpler cases are relieved by the erect posi- 
tion, holding the arms above the head, by 
the reflex effects of cold to the back of the 
neck, or by pressure over the root or sides of the nose. 

If these measures fail, the nostril may be syringed with certain 
solutions: hot water; antipyrin, 5 to 10 per cent., which is especially 
recommended in the Am. Text-book of Surgery; adrenalin, 1 to 
1000. 

The patient must not blow his nose, as this eliminates the clot. 
In the more severe cases try tamponing the anterior nares. If a 
nasal speculum and a good mirror light are available, the anterior 
nares may be systematically plugged through the speculum with 
adrenalin gauze; or, by such means, the bleeding point may be dis- 
covered and touched with the point of the cautery, with silver ni- 
trate, or with chromic acid. 

The International Journal of Surgery gives this practical sugges- 
tion: a layer of cotton is wound' around a pen holder until the de- 
sired thickness is obtained and then withdrawn. The cotton 
cylinder is then moistened, squeezed dry, and inserted into the nasal 
cavity. If the projecting end is now moistened, it will swell up and 
thus produce sufficient compression. 

If these various measures fail, then the posterior nares must be 






. 



EPISTAXIS 



6 9 



plugged. For this purpose, in emergencies, an ordinary soft rubber 
catheter is available, in lieu of the Bellocq cannula (Fig. 56). It is 
threaded and passed directly backward through the inferior meatus 
until its point emerges below the soft palate. The thread is caught 
with forceps, drawn out through the mouth, and held while the 
catheter is withdrawn. One end of the thread projects from the 
nostril and the other from the mouth, and a pledget of cotton is 
tied to this latter end and traction made on the other, by which 




Fig. 56. — Tamponing posterior nares. (Stewart.) 

means the tampon, guided by the index finger, is drawn up behind 
the soft palate and into the posterior nares. When the tampon is 
tied on it, it is a good plan to leave the thread still long enough to 
hang out of the mouth, which will greatly facilitate the removal of 
the plug; otherwise forceps are required or else the tampon will 
have to be pushed backward into the pharynx. Any plug put into 
the anterior nares must be secured by a silk thread, lest, becoming 
dislodged, it may drop into the larynx. The plugs must not be 
left in for more than two days, and should be moistened before 
removal with a mild antiseptic solution. Hertzfeld (J. A. M. A., 
March 13, 1909) describes a case of serious hemorrhage from the 
nasal cavity treated with perborate of soda. A strip of moist 



7o 



HEMORRHAGE 



borated gauze M inch wide was covered with powdered perborate 
of soda and packed tightly into the anterior nares. The hemorrhage 
ceased immediately. The perborate may be insufflated directly 
into the cavity. A grayish- white foam immediately issues, nascent 
oxygen is liberated, and the bleeding checked. 



CHAPTER IX 
WOUNDS. GENERAL PRINCIPLES 

DEFINITIONS 

A wound is the solution of the continuity of the .soft tissues, due 
to trauma. 

(a) Subcutaneous wounds are traumatic lesions of the deeper 
tissues without any definite break in the skin. Such wounds are 
more commonly called " contusions." 

(b) Open wounds are those accompanied by a solution of con- 
tinuity of the integuments. 

i. Incised wounds are open wounds produced by sharp or edged 
instruments. 

2. Stab wounds are those produced by sharp-pointed instruments. 

3. Punctured wounds are those produced by blunt-pointed in- 
struments. 

4. Lacerated wounds are those produced by tearing or crushing. 

5. Gunshot wounds are those produced by projectiles; shot, bullets, 
cannon balls. 

A penetrating wound is one in which the vulnerating instrument 
reaches a body cavity. 

A perforating wound is one in which the vulnerating body passes 
through the cavity. 

An aseptic wound is one in which there is an absence of the germs 
of inflammation. 

A septic or infected wound is one in which the germs of inflammation 
are present. 

A poisoned wound is one in which some agent destructive to tissue 
is present. 

An operative wound is one produced by the surgeon's knife, and 
is presumed to be aseptic. 

71 



72 WOUNDS. GENERAL PRINCIPLES 

SYMPTOMS AND CHARACTERISTICS OF WOUNDS 

All wounds produce more or less pain, hemorrhage, and loss of 
function; in addition, the severer wounds produce constitutional 
disturbances, such as shock, although shock may also occur in slight 
wounds. Hemorrhage depends upon the number and size of the 
blood vessels involved; pain, upon the character of the tissue and 
the extent of nerve injury; loss of function, upon the amount and 
kind of tissue destroyed; shock, upon the mode of injury and the 
tissues concerned. 

Subcutaneous wounds vary widely in the amount of tissue di- 
vided. There may be any degree, from a mere strain of a few fibers, 
with slight intercellular exudation (bruises), to total division or 
widespread laceration of the various layers of subcutaneous tissue. 

The pain is dull and aching. The hemorrhage is usually slight, 
but occasionally may be dangerous. If the hemorrhage is slight, 
it produces merely subcutaneous discoloration, most marked in 
lax tissues; if moderate, it produces an ecchymosis; if serious, a 
hematoma. 

Contusion of the nerves may produce paralysis, usually tern 
porary; or the nerve may be completely divided in subcutaneous 
wounds, and the paralysis be permanent. Shock is nearly always 
present in some degree. 

Treatment. — Subcutaneous wounds are nearly always aseptic, and 
an effort should be made to keep them so. 

The first principle of treatment is functional rest. It may be 
secured in bed, or by the use of splints, slings, or bandages. Mere 
voluntary immobilization is not often sufficient. Apply a cotton 
compress and bandage; a flannel bandage firmly laid on, alone, often 
gives great relief. Evaporating lotions, in the case of superficial 
contusions, often do good. Tincture of arnica and witch-hazel are 
common domestic remedies. 

The following solution, freely and immediately applied, will often 
prevent a " blacked" eye. 

1$ — Ammoni. chloridi., gr. v. 

Alcohol, 5 i. 



i 



INCISED WOUNDS 



73 



Cold, while often giving relief, must be used with caution, since a 
too long application will lower the vitality of the tissues and interfere 
with repair, or will even precipitate death of the injured tissues. 

Heat, in the form of a hot water bottle or hot flannels, is better. 

If the extravasations of blood are moderate, they may be let alone; 
or if persistent and interfering with repair, they may be aspirated. 
In either event, after the inflammatory symptoms have subsided, 
massage is useful to hasten absorption, promote nutrition, and insure 
repair and restoration of function. 

In those cases of severe injury, where 
the subcutaneous hemorrhage is marked 
and continuous, and where a hematoma 
forms, the skin must be incised without 
delay, the clots turned out, the wounded 
vessels secured, and the wound subse- 
quently treated as an open one. 

A workman fell from a scaffold strik- 
ing the gluteal region. He seemed at 
first only severely bruised. A day or so 
later it became apparent that a large 
hematoma had formed. It was aspir- 
ated and a large quantity of blood re- 
moved .but the tumor rapidly reformed. 
It was opened freely and in the torn fibers 
of the gluteus maximus a large vessel was 
found still bleeding. The cavity was a 
long time in healing but no infection occurred. 

Incised wounds are characterized by sharp and severe pain, free 
bleeding, and a tendency to gape. 

The slight actual destruction of tissue, the comparative cleanli- 
ness of a cutting instrument, the free bleeding, and the gaping 
present conditions most favorable for transforming an infected wound 
into an aseptic one, or at least practically so. At any rate, many 
presumably infected incised wounds heal with the same readiness 
and absence of inflammatory symptoms as aseptic operative wounds. 

Treatment. — For the arrest of hemorrhage, ordinarily, a compress 
wrung out of hot water or normal salt solution is sufficient. If 




Fig. 57- — Repair of in- 
fected incised wound of thigh. 
(Veau.) 



74 



WOUNDS. GENERAL PRINCIPLES 



this does not have the desired result, the bleeding vessels are to be 
seized with artery forceps and ligated. The hemostasis must be 
complete. 

The wound is next carefully cleansed of clots and foreign bodies, 
using normal salt solution, sterile water, or very weak antiseptic 
solutions Under favorable circumstances, that is to say, if there 
is a reasonable certainty that the wound has been rendered prac- 
tically sterile, it is closed. If sepsis is feared, a small tube or capillary 
drain must be employed (Fig. 57). 




Fig. 58. — Method of making an incision. (Veau.) 



In the first instance, the wound is as carefully closed by suture 
as an operative one. In the second case, sutures are employed, but 
are placed further apart, leaving the wound free of access for cleans- 
ing solutions and for the free escape of the exudates. If drainage 
is employed, it may usually be dispensed with after the third day, if 
no sepsis arises. 

It is safer to regard all large incised wounds as infected. If the 
wound is closed, it must be carefully watched for signs of infection, 
and, on their appearance, be reopened without delay; or the sutures 
may be placed and left untied until the probabilities of infection 
have been determined. A wound sealed on the surface and infected 
below is a calamity. 

After repair of the aseptic incised wound, a dressing of plain sterile 
or borated gauze is applied, and over this absorbent cotton and 
bandage. 



OPERATIVE WOUNDS 



75 



In certain instances, as with incised wounds of the face, the 
dressing may be dispensed with, the slight serous exudate being al- 
lowed to dry and form a crust, which protection is quite adequate. 

Operative wounds are incised wounds, and the aim is always to 
make and maintain them aseptic. Aside from preliminary steriliza- 
tions, there is a proper method of making these wounds, which is 
essential in keeping them aseptic and promoting repair. 




AM 



Fig. 59. — A good incision. (Veau.) 



The aim should be to do as little violence as possible to any tissues 
incised. The cutting instrument must be sharp, and the tissues 
evenly and smoothly divided. 

To make a good incision, fix and slightly stretch the tissues on 
either side of the proposed line of section, with the left thumb and 
index finger. Never put the skin on the stretch on one side only. 
The first stroke of the scalpel should divide the skin for the whole 
length previously determined (Fig. 58). Decide beforehand, there- 




A.dt 

Fig. 60. — A bad incision. (Veau.) 

fore, the probable length of incision required. The inexperienced 
operator is inclined to make the wound too short and when subse- 
quently it needs to be lengthened it is difficult to keep it straight. 
When the skin and subcutaneous connective tissue are divided, 
identify the deep fascia before incising it; it is an important land- 
mark in nearly every part of the body. All the layers must be cut 
without any gashing or notching;. The incision in the deeper layers 
should not be quite so long as in the superficial layer. The good 
incision gives an equally good view of all parts of the cavity (Fig. 59). 



76 WOUNDS. GENERAL PRINCIPLES 

The bad incision creates irregularities which interfere with inspection, 
not to speak of repair (Fig. 60). 

Stab wounds differ from incised wounds only in their greater 
uncertainties. Their narrowness and depth make it difficult to 
determine what organs and tissues have been involved. 

In order to make a doubtful diagnosis sure, to repair an injured 
structure, to control, hemorrhage, and, to insure antisepsis, it is 
often necessary to enlarge the wound. In other respects these 
wounds are treated on the same general principles as incised wounds. 

Punctured wounds are peculiarly a source of worry. They are 
most prone to become septic for two reasons; first, infection is very 
likely to be carried into the wound, and, second, it is likely to be 
retained. 

The vulnerating instrument is usually unclean; portions of it may 
be broken off and retained; other foreign bodies, such as shreds of 
clothing, sources of infection, may be pushed in and overlooked, 
inasmuch as the narrow tract makes exploration difficult. The 
tissues are not divided, but are pushed apart, and tend to close as the 
instrument is withdrawn. The vessels are little wounded, so that 
bleeding, the best agent for disinfection, for washing out the invading 
microorganisms, is wanting. 

The bottom of these wounds may be shut off from the surface, so 
that the oxygen-hating bacillus of tetanus finds there a congenial 
lodging. 

The treatment for, all these reasons, must be circumspect. In 
doubtful cases, it is better at once to lay open the wound and 
thoroughly disinfect and search for foreign bodies. In any event, 
the wound must be carefully syringed with cleansing solutions. 
Peroxide of hydrogen is particularly indicated if tetanus is antici- 
pated. Antitetanic serum is indicated. If suppuration is threat- 
ened, early and free incision and drainage are imperative. 

Counter openings may be required to facilitate the removal of 
foreign bodies or inflammatory products. 

Lacerated wounds are characterized by the great destruction of 
tissue, comparatively speaking. "They are peculiarly the product 
of modern times." The machinery of rapid transit and manu- 
factory is largely responsible. Boiler explosions contribute a 



LACERATED WOUNDS 77 

number. Gunshot wounds, especially of the face, are likely to be 
lacerated wounds. 

The manner in which the injuries are produced, the tearing and 
crushing of the tissues, gives such injures the following characteristics : 

(1) There is slight primary hemorrhage. 

(2) There is frequently reactionary or secondary hemorrhage. 

(3) Shock is usually present. 

(4) Infection seldom fails to develop. 

(5) Deformity is likely to result. 
The following are the reasons: 

(1) Primary hemorrhage is slight, out of all proportion to the 
destruction of tissue, because the coats of the torn vessels curl up and 
contract, the ragged, uneven surfaces favor coagulation, and the 
presence of shock lowers the blood pressure. 

(2) Reactionary hemorrhage occurs because of the smaller vessels 
losing their plugs of clotted blood when the blood pressure is re- 
stored. Secondary hemorrhage occurs because of the suppuration, 
which is the rule rather than the exception, unless prevented by 
treatment. 

(3) Shock is always present in some degree because of the injuries 
to the nerve trunks. In crushing injuries to the extremities, it is 
sometimes difficult to relieve shock until the mangled nerves are 
completely divided by amputation. Sometimes under these 
circumstances, the shock is immediately fatal. 

(4) Infection is coincident with the injury because of the grime 
which is ground into the tissues. The vitality of the tissues ad- 
joining those which were killed outright is greatly lowered, and the 
power to resist microbic invasion lost. An invading germ and 
lowered vitality are the two factors always essential to suppuration. 

Treatment of Lacerated Wounds. — (i) Hetnostasis, (2) relief of 
shock, 3) antisepsis, (4) support. 

(1) Hemostasis is usually not difficult. It may be necessary to 
catch up a bleeding vessel with forceps and ligate, but more often 
pressure with gauze pads wrung out of hot normal salt solution 
suffices. Unless the hemorrhage is severe, sterilize the adjacent 
skin with soap and water, bichloride, or alcohol, before beginning 
exploration. 



78 WOUNDS. GENERAL PRINCIPLES 

(2) Shock is treated on general principles. Maintain the body 
heat, lower the head, and keep the patient quiet. In severe cases, 
injections of adrenalin and salt solution are to be employed. (See 
shock.) 

(3) Antiseptic measures follow the arrest of hemorrhage and shock. 
Begin by covering the wound with sterile gauze, and then scrub the 
adjacent skin with soap and sterile water, then with bichloride, 
1-2000, and finally with alcohol. Next cleanse the wound. By 
repeatedly flushing with normal salt solution or very weak bichloride 
or other antiseptics, an effort is made to rid the tissues, as much as 
possible, of dirt and debris. 

Porter, of Fort Wayne, says with regard to cleansing wounds 
(American Medicine, September, 1906), that it is an easy matter to 
overdo in our attempts to render an accidental wound aseptic. By 
the use of too vigorous scrubbing, too harsh mechanical means, 
too hot water, or too strong antiseptic solutions, more harm than 
good may be done. The resisting power of the tissues is perhaps the 
most potent single factor in preventing infection, and it may be 
diminished by too much antiseptic zeal. We must remember that 
in spite of our efforts some germs will be left for nature to take care 
of, and we must not make it impossible for her to do it. "Person- 
ally," says Porter, "I find myself using more care, more time, more 
patience, more soap, more water, and less vigorous scrubbing, less 
curettement, and weaker germicides." 

In the author's practice such wounds* are freed of grease and 
grime by pouring on gasoline and then painting very thoroughly 
with iodine; or in the case of cavities the iodine is poured into the 
wound* 

It is not always possible to determine to what extent the tissues 
are fatally injured. In the case of crushed wounds of the extremi- 
ties, it may be necessary to wait until a line of demarcation appears, 
so that no useful tissues shall be unnecessarily sacrificed. 

Drainage is a matter of antisepsis. It is a sine qua non in the case 
of lacerated or crushing wounds, but there is usually little trouble 
in this respect for the reason that these wounds are not sutured 
and drainage is provided for in the dressing. 

(4) Suture of the skin wound is not possible, as a rule, but certain 



INFECTED WOUNDS 79 

of the deeper structures may demand such repair. A divided nerve 
trunk, tendon, or muscle requires approximation. Sometimes 
coaptation of the wound, even though incomplete, will lessen the 
time required for granulation. 

The dressing must fill two requirements; it must absorb the dis- 
charge and also keep out infection. The most commonly employed 
dressing consists of a loose but liberal covering of bichloride or 
borated gauze applied to the wound, and over this a covering of 
absorbent cotton held in place by a bandage, which is applied for 
the purpose also of giving equal pressure and support to the wounded 
tissues. The frequency with which the dressing must be changed 
will depend upon the degree of infection. 

The author has derived much satisfaction in the treatment of 
this class of wounds on the hands from the use of the ointment 
mentioned on page 472. After the wound has been cleansed with 
iodine, the ointment is applied and the whole covered with gauze 
and bandaged. It tends to relieve tension and pain and promote 
repair. The gauze does not adhere to the surface of the wound 
and so the change of dressing is facilitated. 

The aim in general is to disturb the tissues as little as possible, 
and no change is made except to meet the indications for some phase 
of sepsis. 

Infected wounds may not be recognized as such from the first, 
but soon the processes of inflammation manifest themselves. Pain, 
redness and swelling, accompanied by certain constitutional states, 
such as fever and rapid pulse, are the cardinal symptoms. 

The sepsis may produce no results more severe than temporary 
disturbances of the character named. On the other hand, it may 
result in suppuration, which prolongs repair and produces un- 
welcome cicatrices; or, even worse, the infection may spread so 
rapidly as to involve extensive areas, rendering the tissues brawny 
with serous exudates and overwhelming the heart and kidneys with 
toxins before suppuration has time to appear. It is these un- 
certainties which make infection so much to be feared, and make its 
prevention the largest element in the treatment of ordinary wounds. 
When once the sepsis has a definite foothold in a wound, the treat- 



80 WOUNDS. GENERAL PRINCIPLES 

ment has two objects: to destroy the germ and remove and neutralize 
its toxins; and to support the tissues in their struggle. 

Irrigate the wound cavity at least once daily with weak anti- 
septic solutions, such as bichloride, peroxide, lysol, or iodine; provide 
the freest exit for the exudates, employing drainage tubes, if there is 
a cavity. Never pack a suppurating cavity with gauze. Apply a 
moist gauze dressing, moistening it with alcohol, bichloride or boric 
acid, or other antiseptic solutions, or, what is perhaps as well, with 
normal salt solution. This may or may not be covered with ab- 
sorbent cotton. Whatever other qualities the dressing may possess, 
it must be absorbent. Sometimes in the case of the extremities, 
prolonged immersion in warm normal salt solution does good. 

After granulation once begins, it may be stimulated and the 
wound kept healthy by the use of dusting powders, antiseptic oint- 
ments, or balsam of Peru, The latter has been lately very highly 
recommended, in the treatment of wounds generally. 

(For gas bacillus infection see page 285, compound fractures.) 






CHAPTER X 
WOUNDS OF SPECIAL REGIONS 

WOUNDS OF THE SCALP 

Certain anatomical features determine the special character of 
scalp wounds, and must be kept in mind in prognosis and treatment. 

The blood vessels converge toward the vertex; they are the 
occipital, posterior auricular, superficial temporal, supraorbital 
and temporal, any one of which may give rise to troublesome bleed- 
ing, and all of which are subcutaneous instead of subaponeurotic, 
as elsewhere. 

They are firmly connected with the dense tissue of the scalp and 
for that reason do not readily contract when divided; for this reason 
the bleeding from scalp wounds is copious and without much tend- 
ency to spontaneous arrest. The vessels are somewhat difficult to 
catch with artery forceps. 

The aponeurosis of the occipito-frontalis is the dividing line in 
prognosis: wounds that do not penetrate it are less likely to become 
infected, nor do the conditions favor spread of infection. A wound 
perforating the aponeurosis is always a matter of concern; for, ow- 
ing to the loose cellular tissues which connect the aponeurosis with 
the pericranium, an infection may spread very rapidly and in every 
direction. 

All scalp wounds are presumably infected, yet the free bleeding 
minimizes the infection, and the rich blood supply of the tissues 
favors rapid repair. 

Scalp wounds do not gape unless the aponeurosis is divided, and 
contused wounds often resemble incised wounds. 

Contusions may result in the formation of hematoma beneath the 
skin, but they are of little moment. Evaporating lotions are 
sufficient to hasten absorption. 

6 81 



82 WOUNDS OF SPECIAL REGIONS 

A severer injury may cause a hematoma under the aponeurosis. 
Glancing blows, other things being equal, are more likely to cause 
these tumors, rupturing the vessels of the subaponeurotic areolar 
tissue. Such a tumor is likely to be extensive. It may be the 
source of error in diagnosis, giving the examining finger the sensa- 
tion of a depressed fracture, being hard around the borders, and soft 
in the center. If the tumor is of such size as to put the skin greatly 
on the stretch, it may be punctured. This is preferable to inci- L 
sion, for there is less chance of infecting the exudate. 

Absorption always takes place so that the least interference 
possible is the best treatment. 

A hematoma may form under the pericranium, usually in children 
in whom the bone has a rich vascular supply. Here, also, it is ab- 
sorbed in time, and intervention is rarely, if ever, necessary. 

Open Wounds. — The treatment of these wounds, of whatever 
character, may be expressed in certain general formulae. 

The first step consists in cleansing the hair of the blood, which is 
not always an easy task. Warm water is best to dissolve out the 
clots, or peroxide of hydrogen. 

The next step consists in removing more or less of the hair, de- 
pending upon the gravity of the wound. In all serious cases, the 
whole scalp must be shaved. Begin by cutting the hair with the 
scissors, and then apply the razor; the "safety razor" facilitates 
this work. 

Next cleanse the scalp with ether, to dissolve the oil which is al- 
ways present, and follow this with alcohol; otherwise the ether will 
interfere with the soap and water cleansing which follows, and which 
is freely and vigorously applied. 

In the meantime, a light gauze packing prevents the soap and 
water running into the wound. Once the scalp is cleansed, the 
wound itself is to be cleansed. 

Strong antiseptics are distinctly to be avoided. Sterile water, 
normal salt solution, or peroxide are perhaps the best. An irrigator 
or syringe is not to be used, but the solution may be squeezed out 
of a compress into the wound. Be assured that every particle of 
foreign matter is out of the wound before considering repair. 



AVULSION OF THE SCALP 83 

Complete hemostasis is an essential to rapid healing, and the time 
and patience spent in securing it are by no means lost. If the 
bleeding vessels cannot be ligated in the ordinary way, the ligature 
may be carried on a needle through the tissues surrounding the 
vessel. The oozing may be entirely controlled by a few minutes' 
pressure with a hot antiseptic compress. The main thing is not to 
get discouraged or be in too great a hurry. 

The cleansing and hemostasis completed, the coaptation follows. 
In the case of contused wounds, the ragged edges are to be trimmed. 
The suturing is an important step in facilitating reunion. Even 
wounds that do not gape heal all the more quickly for suturing, silk 
being probably the best material. 

In many cases of incised wounds which are not deep, the suturing 
may be firm and no drainage required. In the great majority of 
cases, however, drainage is necessary, and may be secured by in- 
complete suture, by a tube, or, following Von Bergman, by strips of 
gauze or rubber tissue. 

The dressing will usually consist of sterile gauze and absorbent 
cotton held in place by bandage. In the case of minor wounds, 
and where no infection is feared, it is sufficient to smear the line of 
suture with sterile vaseline and cover with flexible collodion. 

If a large segment of the scalp has been loosened, every effort 
must be made to readjust and suture it accurately, though the drain- 
age must be ample. Oftentimes with those who have been even 
almost completely scalped, the results have been excellent. 

Flaherty reports a case of complete avulsion, occurring in a 
laundry worker. There were areas of denuded bone. There was 
no shock and but little hemorrhage. The woman who was alone 
at the time of the accident remained perfectly conscious and after 
extracting herself from the machinery, stopped the motor and 
wrapped a towel around her head. 

Hot boric acid compresses were applied without further cleans- 
ing and after four days Thiersch grafts taken from the thigh were 
applied to one side of the head and a week later to the other side. 
The denuded bone was trephined through the outer table that 
granulations for grafting might form. Pursuing this line of treat- 
ment the patient was enabled to leave the hospital in two months 



84 WOUNDS OF SPECIAL REGIONS 

with head covered with good firm skin. (Annals of Surgery, Feb., 
1914.) 

WOUNDS OF THE PINNA 

Many forms of injury befall the ear. It may be bruised, cut, or 
lacerated, and much or little of it lost. Even a slight loss is a dis- 
figurement, and any very serious loss of tissue results also in some 
disturbance of hearing. 

A laborer came intojthe City Dispensary with half an ear cut off 
and hanging by a mere thread of tissue. The sharp edge of a spade 
wielded by a co-worker had produced the injury. The almost dis- 
carded member was carefully sutured in place with silk. Some 
sloughing occurred along the edges of the wound but eventually the 
repair was complete and almost without a scar. 

These tissues possess great vitality, and the completeness of re- 
pair after much mutilation is often surprising. Large portions of 
the ear may be cut off completely, and yet if immediately sutured 
in careful coaptation, union will occur. There may be some slough- 
ing along the line of union, but eventually there is but little scar 
tissue left. In every case, then, of incised wound, an effort must be 
made to suture. The hemostasis must be complete, and if there is 
much laceration, the edges of the wound must be trimmed. Silk 
is the best suture material in these cases. 

WOUNDS OF THE FACE 

Accidental wounds of this region, more than any others, approxi- 
mate aseptic wounds. These wounds do not gape much; the tissues 
are very vascular, so that the conditions are most favorable for re- 
pair. The chief aim is to avoid scar tissue and the consequent dis- 
figurement. To attain that end the suturing must be delicate, the 
coaptation perfect. The sutures must be as small as possible and 
as few as possible. 

The subcutaneous stitch may be employed if the wound is ex- 
tensive and deep. In ordinary incised wounds extensive dressings 
may be dispensed with, and the line of suture may be covered 
with collodion or, as Von Bergman, who dislikes collodion, suggests, 



WOUNDS OF THE EYELID 



85 



the wound may be amply protected by the scab formed by the 
dried exudates. 

WOUNDS OF THE LIPS 

Wounds of the lips are likely to bleed considerably, but the 
hemorrhage is easily controlled by compressing the lip between the 
thumb and index finger, and then 
the coronary artery may be lig- 
ated on each side of the wound. 

When the division is complete, 
begin the repair by suturing the 
mucous membrane (Fig. 61) with 
catgut. Suture the skin by con- 
tinuous or interrupted suture of 
fine silk or catgut. The greatest 
care must be exercised when the 
border of the lip is reached; the 
coaptation must be exact or the 
result will be a disappointment. 

A small drain in the skin 
wound is usually advisable. 




Fig. 6i. — Suturing wound of lip. (Veau.) 



WOUNDS OF THE TONGUE 

Wounds of the tongue, which are not. as infrequent as one might 
expect, may give rise to a disagreeable hemorrhage. 

The tongue is to be drawn out of the mouth and compressed with 
the fingers above the wound or by a pair of forceps covered with 
rubber tubing or with gauze (Fig. 62). 

Suture the bleeding points, employing deep sutures of catgut, 
No. 3. Every quarter hour the mouth should be washed with a 
solution of chloral, 2 grains to the ounce, until the oozing and pain 
have subsided. 

WOUNDS OF THE EYELID 

A wound of the eyelid is to be repaired like a wound of the lip, 
by two lines of suture. First suture the mucous membrane with 



86 



WOUNDS OF SPECIAL REGIONS 



fine catgut. Then begin the suture of the skin at the free border, 
where the edges of the divided tarsal cartilage are to be very ac- 
curately coapted (Fig. 63). If drainage is used, it must be small 
and project from the middle of the wound. 







Fig. 62. — Suturing wound of tongue. A, tongue controlled by tenaculum forceps. B, first 
suture passed and tied. C, second suture passed, using the Reverdin needle. (Lejars.) 



WOUNDS OF THE NECK 






One has but to consider the multiplicity of the structures in the 
neck to realize that wounds of this region are likely to be complicated. 

Whether the wound be incised or contused, a stab or a gunshot 
wound, there are dangers that arise from hemorrhage, asphyxia, 
and infection. 

The most common wounds, perhaps, are those which arise from 
attempts at suicide. That these attempts are often abortive, and 
the danger done much less than one might expect, are due to the 
fact that the tissues are yielding and the vessels recede as the head 
is thrown back; the knife may be directed against the lower jaw or 
spend its force on the cartilages or hyoid bone; the arm may lose its 



WOUNDS OF THE NECK 



87 




force at the moment the larynx is opened, or from failing resolution. 
In these attempts at suicide, the wound in right-handed people usu- 
ally begins on the left side high up, and runs obliquely downward to 
the right, becoming less and less deep. Not infrequently the wound 
may appear jagged, or give the impression of two or three slashes, 
from the folding of the skin before the pressure of the knife (Fig. 64). 

In the graver cases, hemorrhage is usually the first consideration. 
If a carotid is wounded, a geyser of blood spurts out and the patient's 
life is in the hands of the first comer, for there is no time to call for 
skilled aid. If the internal jugular is wounded, the hemorrhage is 
scarcely less dangerous and per- 
haps even more difficult definitely 
to control. Air may enter the 
venous circulation and death im- 
mediately ensue. In either case 
anything but intelligent first aid 
will fail. 

The carotid may be controlled 
by pressure downward and back- 
ward at the base of the neck, com- 
pressing the vessel against the 
transverse process of the sixth cervical vertebra; or the bleeding may 
be temporarily controlled by direct pressure on the bleeding vessel 
in the wound. 

When the surgeon arrives upon the scene, he finds the wound 
filled with a great clot, for it cannot be expected that the first aid 
will do anything more than partly check the bleeding. His first 
effort must be to cleanse out the clots and locate both ends of the 
bleeding vessels, clamp them, and ligate. Blind clamping of the 
tissues en masse is absolutely unsurgical. If the ends of the divided 
vessel cannot be located, the wound is to be enlarged over the course 
of the vessel, using the anterior border of the sternocleidomastoid 
muscle as a guide. If the character of the wound or the region pre- 
clude that, then the artery must be exposed below the wound and 
ligated. It may happen, especially in secondary hemorrhage, that 
the carotid on the opposite side also may need to be ligated either 
temporarily or permanently. 



Fig. 63. — Incised wound of upper lid. 
Tarsal cartilage sutured first. (Veau.) 



88 



WOUNDS OF SPECIAL REGIONS 



The internal jugular may be difficult to expose and ligate because 
of its thin and friable walls. Even small openings in the vessel 
may call for circular ligation, for lateral ligation is usually unsatis- 
factory. Outside of the hospital, suture can scarcely be considered. 




io 98765 3 21 

Fig. 64. — Incised wound of neck involving the larynx. 1, platysma; 2, sterno-mastoid ; 
3, int. jug. vein; 4, vagus nerve; 5, ext. jugular vein; 6, com. carotid art.; 7, upper part of 
wound in thyroid cartilage opening into larynx; 8, sup. thyr. art.; 9, st. hyoid muscle; 10, 
sterno-thyroid muse. 



If the trachea, in its upper part, or the larynx is opened, it is better 
to do a tracheotomy lower down and attempt repair of the wound. 
In many cases, however, if the wound is not extensive, it is sufficient 



INJURIES TO THE EYE 89 

to close the wound by flexing the neck, omitting the sutures, and 
leaving nature to repair the opening in the air passage. 

If the esophagus or pharynx is perforated, repair should be at- 
tempted; but drainage must be employed and the external wound 
left partly open, for, in the act of swallowing, particles of food may 
be forced into the wound to set up infection. 

If infection or inflammation of the respiratory tract arises, it is 
to be treated on general principles. 

Divided nerves should be repaired if possible, although often the 
difficulties are too great to surmount. 

A woman, the victim of a murderous assault, was brought to the 
City Hospital with a gaping razor cut straight across her throat. 
The hemorrhage had been checked by the ambulance surgeon who 
had applied three or four clamps. She was anesthetized with some 
difficulty. It was found that the structures connecting the hyoid 
bone and the thyroid cartilage were severed — in other words the 
pharynx was opened widely and with each inspiratory effort the 
epiglottis protruded into the wound. 

An effort was made at an anatomical repair and with some success. 
The mucous membrane was fairly well coapted with interrupted 
sutures of plain catgut. 

Next all the small bleeders were tied and the muscle ends brought 
together with mattress sutures of chromic gut; the fascia next with 
chromic, and finally the skin was repaired with silkworm-gut 
Rubber tissue drainage was used on either side of the middle line 
extending down to the muscle layer. 

Following the repair, swallowing was exceedingly painful and the 
secretion of mucous excessive. Rectal feeding was necessary for 
three days. 

The subsequent course of the case was remarkable. Her pulse 
and temperature remained normal, there was not the slightest evi- 
dence of infection and she left the hospital at the end of two weeks 
with a light scar as the only evidence of her terrible experience. 

WOUNDS OF THE EYE 

Morrison, of Indianapolis (Indiana Medical Journal, Feb., 1907), 
has defined the injuries of the eye, whose treatment must most often 



90 WOUNDS OF SPECIAL REGIONS 

be instituted by the general practitioner. From the diagnostic 
point of view, he classifies them under two heads: 

(a) Those without superficial lesions of the ball. 

(b) Those with more or less extensive open wounds. 

(a) The first may lead the practitioner into grievous error in prog- 
nosis and injudicious lack of treatment. No blow over the eye should 
ever be considered lightly. While the majority of such cases lead to 
no serious consequences, the exceptions are of^sufficient frequency 
to be of importance. 

It is possible for the so-called " concussions' ' to lead to subsequent 
inflammation or degeneration of the deeper structures of the eye. 
So, then, though no treatment is to be instituted in the absence of 
symptoms, yet the case must be kept under observation for some 
time, the vision tested, irregularities of the pupil noted, and evi- 
dences of inflammation sought for. 

On the other hand, there may be a hemorrhage into the anterior 
or posterior chambers, accompanied by pain, protrusion of the eye- 
ball, and swelling of the lids. Under such circumstances, put the 
patient to bed at once and apply ice cloths to the eye, this treatment 
to be kept up until the symptoms begin to subside, when it is 
probable that the blood has clotted and the hemorrhage ceased. 

In addition to, or instead of hemorrhage, there may be disarrange- 
ment of the retina, lens or iris, accompanied by disturbance or 
destruction of vision. 

Put the patient to bed in a darkened room, and drop into the eye 
a solution of atropine, 4 grains to the ounce, followed by the ap- 
plication of cold cloths for at least twenty-four hours. Later a 
bandage is to be applied and the patient permitted to go about. 

Any subsequent disturbance calls for an examination by an oculist. 

(b) Deep, penetrating, non-infected wounds of the globe are serious 
in various degrees, depending upon the region involved, though they 
usually heal kindly. Injuries of the sclero-corneal junction or ciliary 
body often lead to sympathetic ophthalmia, and may require early 
or late enucleation. 

The treatment is simple. Prevent infection by the free use of 
boric acid solution, followed by one or two drops of the atropine 



SUTURE OF THE CONJUNCTIVA 9 1 

solution, and the application of a sterile eye dressing. Rest in bed 
is indicated. 

Every wound of the sclera of any moment requires suture, which 
is the best means of preventing infection. Infected wounds require 
an immediate and circumspect treatment. 

If the vitreous is involved, the eye is almost certain to be 
lost. The prognosis is somewhat better if the cornea alone is 
involved. 

The eye is to be irrigated with warm, sterile, saturated solution 
of boric acid, followed by a few drops of the atropine solution, the 
whole to be repeated every two or three hours, until the redness 
passes away. In the meantime, heat or cold is to be applied, de- 
pending upon which gives the most comfort, except in the case of 
the cornea, where heat is always the better application. 

Morrison recommends as the best eye pad, several thicknesses of 
sterile gauze held in place by a single thickness of bandage or a 
strip of adhesive plaster so that it can be frequently changed. 

To sum up, then, the chief ends of the emergency treatment are 
two; asepsis and conservation. Only very rarely will the question 
of enucleation present itself as an emergency. The careful ex- 
amination which should be given every injured eye, should be pre- 
ceded by a regulated asepsis. Prepare the hands; prepare the orbital 
and palpebral regions by patient washing with warm sterile water 
and soap, avoiding all pressure or rough handling which may aggra- 
vate the ocular lesions. Cleanse the conjunctiva of the grosser 
dirt and immediately instill a few drops of cocaine solution. In a 
few minutes the cleansing of the globe and palpebrae may be com- 
pleted without pain, and a careful examination made and the treat- 
ment instituted. 

If suture is required, use a small curved needle held with a forceps, 
employing catgut No. oo, and above all, a minute care and a light 
hand. 

The suture should not pass through the entire thickness of the 
sclerotic coat, but only through the conjunctiva or the most super- 
ficial layers of the sclera. The reunion will usually be perfect if 
the sutures are carefully passed and slowly tied. (See, also, Foreign 
Bodies.) 



9 2 



WOUNDS OF SPECIAL REGIONS 



WOUNDS OF THE EXTREMITIES 

Wounds of the extremities call for varied application of all the prin- 
ciples of treatment of wounds, hemostasis, antisepsis, and suturing. 

Only through familiarity with these principles will one acquire 
address in the management of the individual case, for no two injuries 
are exactly alike. It will be advantageous to exemplify these prin- 
ciples with special reference to wounds of the extremities. 

INCISED WOUNDS OF THE WRIST 

Such wounds are frequent and their repair is usually left to the 
junior surgeon; the task is, however, no light one and the functional 



ISP 



ccM 



/C*£P. 




•-JKC 



jir.k %p W 



Fig. 65. — Cross section showing relations of the various tendons at the wrist-joint. 
N. R., radial nerve; L.F.P., long flexor of the thumb; A.R., radial artery; G.P., palmaris 
longis; N.M., median nerve; L.F., flexors of the fingers; A.C., ulnar artery; N.C., ulnar nerve; 
C.P., ext. carp, ulnar; C.P.D., ext. min. dig., C.C.D., ext. com. digitorum; L.E.P., ext. long 
pollicis; R, extensors carp, rad.; M.P.; supinator longus extensor brev. pollicis. 






results are often a source of embarrassment to the operator. To 
locate (and identify all these tendons and nerves, to get the proper 
ends in contact, to repair them and, above all, to avoid infection 






WOUNDS OF THE EXTREMITIES 



93 



requires no end of patience and no little skill. The management of 
these wounds is largely a matter of applied anatomy. 

In the more superficial wounds the palmaris longus alone is di- 
vided, a quite small tendon in the middle 
line of the wrist. 

A little deeper on the radial side of 
the middle line, the flexor carpi radialis 
may be involved; or far out on the ulnar 
side, the flexor carpi ulnaris, in the line 
of the pisiform bone. 

If a still deeper plane is reached the 
radial artery on the radial border, the 
ulnar artery on the ulnar border may re- 
quire a ligature. The ulnar nerve lies to 
the ulnar side of the ulnar artery, and 
little deeper. In the middle line in this 
deeper plane are the flexors of the fingers 
and the median nerve (Fig. 65). 

The bleeding in such cases is usually 
copious. 

Begin the treatment by elevating the 
arm and applying circular constriction for 
temporary hemostasis (Fig. 66). 

Next sterilize the field and then the 
wound itself. Separate the lips of the 
wound, locate and clamp the superficial 
veins (Fig. 67). These are not of much 
importance yet are large enough to make 
troublesome bleeding. Search for the 
artery; both ends must be ligated, the 
companion vein included. 

It may be necessary at this time to 
enlarge the wound, for the skin may be 
much less extensively involved than the 
deeper parts. 

It is of great assistance to mobilize the lips of the skin in order to 
expose and facilitate the repair of the deeper structures. Remove 




Fig. 66. — Incised wound of 
wrist. Tourniquet applied. 
(Veau.) 



94 



WOUNDS OP SPECIAL REGIONS 




Fig. 67. — Incised wound of wrist. Bleed- 
ing vessels clamped. (Veau.) 



Fig. 68. — Incised wound of wrist. 
Vessels ligated. (Veau.) 




Fig. 69. — Wound at bend of elbow. 1, Basilic vein; 2, median cephalic vein; 3, biceps 
tendon; 4, bicipital fascia; 5, brachial artery; 6, brachial vein; 7, median nerve. 



WOUNDS OF THE EXTREMITIES 95 

the tourniquet, complete the hemostasis, and proceed to determine 
the injuries to tendons and nerves. (For methods of repair see 
page 347.) 



WOUND AT THE BEND OF THE ELBOW 

The importance of the structures at the flexure of the elbow call 
for special reference to incised wounds in this region. They are 
not infrequent. 

Superficially, on the inner side, is the median cephalic vein; on 
the outer the basilic vein; below these the bicipital fascia, an im- 
portant landmark just beneath which, in the middle line lies the 
brachial artery with its vein to the inner side. The median nerve 
lies also to the inner side; and deeply placed in the middle line is 
the tendon of the biceps. Failure to repair any of these structures 
may lead to serious disability. The bicipital fascia should be re- 
paired by a separate line of sutures (Fig. 69). 



A STAB WOUND OF THE THIGH 

(Fig. 70.) 

The femoral has been wounded and the hemorrhage is furious. 
Direct an assistant to make firm digital pressure over the artery 
as it crosses the pubes, nor must this pressure be relaxed. If his 
fingers tire, a second assistant may press upon the fingers of the 
first (Fig. 71). Enlarge the wound freely in both directions in the 
course of the artery. Sponge out the clots; identify the aponeurosis 
and divide it in order to expose the artery; isolate the artery by 
careful blunt dissection and find the two ends, which is often difficult 
when the artery is completely divided (Fig. 72). 

When both ends are found, ligate with catgut No. 3, or silk No. 2, 
(Fig. 73). Tie the injured vein next both above and below. It is 
to be tied separately from the artery (Fig. 74). The possibility of 
including a nerve in the ligature must always be borne in mind and 
no ligature is to be finally tied until certain that no nerve is to be 
thus compressed, to become later a source of pain. Remove the 



96 



WOUNDS OF SPECIAL REGIONS 



pressure and catch any more vessels that might bleed; employ free 
drainage and suture incompletely. 

Apply sterile gauze dressing, absorbent cotton, and a bandage, 
making moderate pressure, and maintain the limb in moderate ele- 
vation. Renew the dressings on the third day, and if there are no 




Fig. 70. — Stab wound of thigh. 
(Veau.) 




Fig. 71. — Stab wound of thigh. Com- 
pressing artery while the wound is en- 
larged. {Veau.) 



complications, remove the drainage. Remove the sutures about 
the eighth day. 

Certain complications may arise. If the ligatures were imperfect, 
hemorrhage may ensue; the operation has to be repeated and the 
vessels tied again. If infection occurs, if the temperature reaches 



WOUNDS OF THE EXTREMITIES 



97 




Fig. 72. — Exposing the wounded vessel. (Veau.) 




Fig. 73. — Isolating and ligating the artery. Fig. 74. — Ligating the vein. (Veau.) 
(Veau.) 



98 WOUNDS OF SPECIAL REGIONS 

ioi° F., open up the wound and establish better drainage, which is 
the best means of preventing secondary hemorrhage. Gangrene 
sometimes follows the ligation of a main artery. Watch the tem- 
perature of the extremity and look for pulsation in the arteries be- 
low the ligature. If pulsation is present, be in no haste to amputate. 
If gangrene does not develop before the fourth day, it is not likely 
to do so. 

Crushing and lacerating wounds of the extremities, as Lejars 
says, give rise to the most perplexing problems of emergency surg- 
ery. The questions present themselves in this form: To amputate, 
or not to amputate? and if the latter, when, at what point, and by 
what method? 

In order not to be vacillating in his treatment, every doctor must 
have his principle of action settled once for all. 

Lejars states his guiding principle and rule of action in this manner: 
Above all, save the patient's life; save the limb wherever possible, 
or at least limit the mutilation to the minimum. 

Clinically, he places these injuries in two groups: (a) those in 
which a segment of the limb is crushed or otherwise injured without 
peripheral involvement, and (b) injuries extending from the hand or 
foot upward. 

(a) Suppose a case: An arm has been run over by the wheels of a 
heavy vehicle. The member is flail-like, although the skin is not 
broken, and there are no particular points of bleeding. Palpation 
through the skin over the injured segment shows that the deeper 
structures have been reduced to a pulp, both muscle and bone. 

Still, below the wound, the radial and ulnar arteries are found to 
pulsate. This is an absolute indication against amputation. The 
immediate treatment must be limited to a careful disinfection of the 
member, the repair of any superficial wounds, a complete envelop- 
ment in absorbent cotton, and immobilization. 

The immobilization is an essential feature, for by that means 
any bending and stretching of the vessels is prevented and repair 
favored. If the skin is broken and the bone crushed or shattered 
and exposed, the injury is a compound fracture and is to be dealt 
with accordingly, but the prognosis always depends upon the blood 
supply. 



WOUNDS OF THE EXTREMITIES 99 

If in the case instanced, there is absolutely no pulsation in the 
principal arteries, it is certain that a part of the limb is lost; yet an 
immediate operation is not indicated. There are two reasons for 
this; first, that the shock may subside, and second, that too much 
of the limb may not be sacrificed, which latter an immediate ampu- 
tation nearly always means. 

Proceed to a most rigorous disinfection and await a line of demar- 
cation. This is the rule to which there are two exceptions, one 
apparent, and the other actual. 

If the injury is a crushing one and the member hangs by shreds of 
tissue, there is absolutely no use in waiting; but the completion of 
the ablation does not require an amputation, it is merely what 
Lejars terms a "regularization." 

Trim up the tissues sparingly and remove enough bone that a 
proper stump may be formed, and then patiently cleanse the wound 
with hot sterile water or normal salt solution, followed by alcohol. 
Suture completely and then cover the wound with sterile gauze 
saturated with alcohol; finally cover all with a thick layer of cotton 
firmly bandaged. 

Almost always by this means a better functional result may be 
obtained than by a formal amputation quite above the site of 
injury. 

There is an actual exception to the rule of conservatism. The 
case is seen late and there are already signs of approaching infection. 
It is not safe to delay and risk the sepsis which menaces. It is better 
under such circumstances, to proceed to immediate amputation. 

(b) Crush or laceration extending from the hand or foot upward. 

Suppose you are called to treat the foot and part of the leg, or a 
hand and part of the f orearm, which have been crushed and lacer- 
ated. The member appears injured beyond remedy. Will you imme- 
diately proceed to amputate? By no means — or at least, not as a 
rule. 

If the case is seen immediately, the first effort should be devoted 
to combating shock and infection. 

It is not altogether on account of shock that one waits; there are 
other even more important reasons. The first is that you may not 
amputate high enough; the second, that you may amputate too high. 



IOO 



WOUNDS OF SPECIAL REGIONS 



One cannot always determine from the first how high the devitalized 
tissues extend. There may be vascular injuries or muscular lacera- 
tions which are concealed by a sound integument, and which may 
later be the source of gangrene. Out of this grows the necessity of a 
secondary amputation, which is always a matter of chagrin to the 
surgeon and an element of danger to the patient. 

On the other hand, tissues which appear devitalized may finally 
survive and thus preserve a function which might otherwise have 
been sacrificed. 

It is true that a few inches more or less of the arm or leg, for in- 
stance, may make no great difference in the usefulness of the stump; 
it is quite otherwise when the question is that of amputating im- 
mediately above or below the 
elbow or the knee, or through 
them. Nor do rules of con- 
servation apply with equal 
force to the foot and the hand. 
Injuries of similar degree 
affecting the upper or lower 
extremity demand different 
treatment, because of the much 
greater freedom of collateral 
circulation in the former, render- 
ing gangrene less probable. 
Where conservatism or ex- 
cision would be proper in the upper extremity, amputation would 
be called for in the lower limb. 

Extensive comminution and loss of bone of the foot may demand 
amputation because, if saved, the member may be useless as a means 
of locomotion, and should give way to a vastly more useful artificial 
limb. 

Great laceration of the soft parts of the foot, with free comminu- 
tion of bone and injury to vessels, always demands amputation; 
for the destruction of the skin of the heel and sole will result in a cica- 
trix which can never bear the weight of the body and may never be 
anything but a source of suffering and discomfort to its possessor. 
But, aside from these exceptions and others to be noted, the rule 




Fig. 75.- 



-Ball of gauze for support of fingers. 
{Mar see.) 






WOUNDS OF THE EXTREMITIES 



IOI 




Fig. 



76. — Thumb pinched off leaving square- 
ended stump. (Marsee.) 



holds in this class of injuries, to avoid amputation and devote one's 
skill to preventing infection. The prevention of infection is the 
sine qua non; if the efforts in this direction are going to be half- 
hearted, it is better to amputate 
at once. 

Immediate amputation, again, 
is indicated if the wound is 
seen some hours after the acci- 
dent, and is found soiled and 
dirty and manifestly infected. 

Under these conditions, con- 
servation is not the best course, 
for there are too many chances 
that the attempt at disinfection 
will fail; that, in spite of the 
best efforts, sepsis will arise. 
Or, if there are already present 
the symptoms of dangerous sepsis, it is no longer a question of 
saving a limb, but of saving a life, and it will be the part of con- 
servatism to amputate well above the 
suspected level. 

With regard to the conservative 
treatment of these severe crushing and 
lacerated injuries of the hands and feet 
which most surgeons would be prone to 
amputate, Reclus, of Paris, has empha- 
sized the value of thorough and patient 
disinfection of the skin and then of the 
wound, together with a trimming away 
of the devitalized fragments of skin and 
bone. He then " embalms" the mem- 
ber in gauze saturated with an anti- 
septic pomade, crowded into all the 
recesses of the wound, and the whole 
covered by a thick dressing of absorbent cotton and bandaged. This 
dressing is left undisturbed until repair is complete, unless the tem- 
perature should rise ora disagreeable odor develop. 




Fig. 77. — Same, 
pleted. 



Amputation com- 
(Marsee.) 



102 



WOUNDS OF SPECIAL REGIONS 




Fig. 78. — Amputation of index finger. Head 
of metacarpal retained. (Marsee.) 



Joseph Marsee (Ind. Med. Jour., April, 1896) has made some 
useful observations with respect to the treatment of common injuries 
of the handy which are well worth repeating and which, as he points 

out, appeal especially to the 
young man just beginning his 
life's work, for such will prob- 
ably constitute the bulk of his 
surgical practice for some 
years. There is a natural 
tendency, in the popular mind, 
to measure an injury by the 
size of the member involved, 
and the man who would insist 
upon the best advice in other 
cases, will fly to the nearest 
doctor's sign when "only a 
finger" is involved. But Marsee concludes, from his own experi- 
ence, that the young practitioner is an accomplice in spoiling a 
good many hands before he learns to do them justice. On the 
other side, it is not too much to say that the best human skill is 
none too good when employed 
in repairing injuries of the 
most mechanically perfect 
human member. 

The majority of these in- 
juries occur in workers with 
machinery; the hand, therefore, 
is always soiled and generally 
greasy. This grease must first 
be removed. Nothing is better 
for this purpose than ordinary 
gasoline or benzine, which may 
be poured into the hand 
directly from the bottle. The 
fluid will find its way into the 

smallest recesses of the wound, washing out the grime and preparing 
the way for the other antiseptics. The benzine is poured on until 




Fig. 79. — Amputation of index finger. 
Head of metacarpal removed making much 
more sightly hand. (Marsee.) 



INJURIES TO THE HAND 



IO3 




Fig. 80. — Loss of ring finger. 
Dorsal view. (Marsee.) 



all the grease is removed, and the disin- 
fection is completed in the ordinary way. 
Even slight wounds of the fingers and 
palms should be treated by enforced rest 
by a splint or plaster-of-Paris dressing, 
complete enough to preclude all motion. 
This prophylaxis is not regarded as un- 
necessary by those who have seen the most 
marked deformities, the gravest constitu- 
tional disturbances, and even death, re- 
sult from trifling wounds of the hand. 
Enforced rest which leaves nothing to 
chance, to caprice, or the patient's med- 
dling is alone reliable. Under such treat- 
ment, the rapidity with which alarming 
symptoms sometimes disappear is truly remarkable. If a plaster 

casing is used, it should extend from 
several inches above the wrist to 
the extreme tips of the fingers, the 
thumb being also enclosed if neces- 
sary. 

When finger wounds are extensive 
and parallel with the long axis, it is 
better not to suture them at once, 
for the swelling will generally be ex- 
tensive and the stitches will cut out. 
After the inflammation has subsided, 
the edges may be freshened and ap- 
proximated. Nor does Marsee ad- 
vise immediate splinting in the case 
of crushing injuries of the fingers, for 
fear that the circulation may be in- 
terfered with. However, that the 
crushed member may not be wholly 
Fig. 81.— The loss of the ring finger unsupported, a soft ball covered 

is hardly noticed when the distal half ^ d wrapped with e 

of the metacarpal bone is excised. ^^ ° 

{Marsee.) is applied to the palm so that the 




104 



WOUNDS OF SPECIAL REGIONS 



fingers may be spread out over it comfortably (Fig. 75), and the 
whole dressed with absorbent cotton and lightly bandaged. The 
ball, as Marsee indicates, though unsightly and bulky, has no other 
fault; it is light, absorbent and wonderfully comfortable, and needs 
only a trial to be appreciated and adopted. It should be used 
until the tissues are beyond danger, though it takes several days, 
a week or a month. No time is lost, for healing cannot begin until 
vitality is restored, and this will always be slow in such cases, a 

fact which should be brought 
thoroughly to the patient's 
knowledge from the beginning, 
that the doctor may not be 
blamed for the tardy convales- 
cence. 

With regard to methods of 
amputating fingers, opinion is 
divided on the question as to 
which is the more desirable, a 
palmar flap, or a slightly longer 
finger with a dorsal flap cover- 
ing the stump. 

There can be no douot that 
a palmar flap is desirable, and 
Marsee believes in securing it, 
even at the expense of sacrific- 
ing more of the finger. If more 
than half the phalanx is gone, 
it is always better, in his opinion, to amputate at the joint line and 
thus avoid a flexed stump. 

If a portion of the distal phalanx remains, the nail should be re- 
moved and the matrix dissected before the flap is adjusted, or some 
deformed fragment of nail may be left to vex the patient. It is 
better, in removing a finger at a joint, to cut off the knobby pro- 
jections of the condyles on the palmar surface and to scrape off the 
exposed cartilage. 

If the finger is pinched off squarely, one must always insist in re- 
moving enough of the bone to give a good flap, for if the patient has 




Fig. 82. — The stump of the index finger 
falls away from thumb when head of middle 
metacarpal has been removed. (Marsee.) 



WOUNDS OF THE VULVA 105 

his way and the stump heals by granulation, the result will be unsatis- 
factory and the doctor, eventually, will have to bear the blame 
(Figs. 76, 77). 

If the whole finger requires amputation, the head of the meta- 
carpal bone will require special attention and the procedure will be 
different with the different ringers. 

Remove the heads by oblique section in the case of the index and 
little fingers (Figs. 78, 79). Generally remove the head of the meta- 
carpus in the case of the ring finger, cutting back far enough to let 
the heads of the adjacent bones fall together (Figs. 80, 81). 

Do not remove the metacarpal head of the middle finger unless the 
appearance of the hand is the chief consideration. Marsee states 
as the reason for this, that it tends to let the other fingers fall away 
from the thumb and thus interferes with ready apposition (Fig. 82). 

WOUNDS OF THE VULVA AND VAGINA 

The chief danger in wounds of these parts is hemorrhage, especially 
when the vulva is involved and its venous plexuses torn. These 
wounds may be contused, lacerated or punctured, and more fre- 
quently occur from falls astride some object, and by that means the 
bulb of the vagina is crushed against the ramus of the pubes. 

Forcipressure and ligation may be ineffectual to control the bleed- 
ing and often the only recourse is tamponade, first disinfecting the 
wound and the region adjacent, and afterward applying a T bandage 
and bringing the thighs firmly together. 

Perforating wounds of the vagina call for a most careful examina- 
tion, for not only may the vaginal walls be involved, but the rectum, 
bladder, or peritoneum as well. Careful suturing is here the best 
means of controlling hemorrhage. Peritonitis may result from such 
injuries or more remotely, fistulae or astresia of the vagina. 

Any serious hemorrhage following coitus calls for an examination. 
It may ensue from a tear of the hymen, or of the posterior wall of 
the vagina. Cases are on record in which the tear penetrated the 
rectum. 

Deep suturing serves at the same time to control hemorrhage 
and to promote repair. 



io6 



WOUNDS OF SPECIAL REGIONS 



WOUNDS OF THE PENIS, SCROTUM AND TESTICLE 

The penis may be fractured nearly always during coitus and in 
the subjects of a previous gonorrhea which has produced an area 
of least resistance in some of the peri-urethral structures. Usually 
the corpus spongiosum is torn. 

Immediately the organ becomes flaccid but within a few minutes 
again enlarges, this time due to the edema. The extravasated blood 
produces at once the great discoloration and the acute flexure which 
is typical. 

Unless the extravasation is very large and progressive, there is 
nothing to do but to bandage the organ and put the patient at rest. 



A 




Fig. 83. — B, wound of testicle repaired. C, Tunica vaginalis. A, Beginning its repair. 

Otherwise it will be necessary to expose and suture the break in 
the corpus cavernosum and this Legueu advises as likely to give the 
best functional result. But with such a procedure one may expect 
a severe hemorrhage. Open wounds of the erectile tissues of the 
corpora cavernosa or corpus spongiosum may be expected to bleed 
freely. It is usually advisable to pass a sound to determine the 
integrity of the urethra, suturing it first, if involved, and then care- 
fully coapting the erectile tissues. 

In the case of wounds of the scrotum merely the integuments may 
be penetrated, or more deeply the tunica vaginalis or the testicle as 



WOUNDS OF THE TESTICLE 



IO7 



well. It must be remembered that any considerable wounding of 
the tunica of the testicle may result in hernia of the parenchyma. 

The scrotal tissues must not be roughly handled in cleansing, and 
the sutures must not be too tight, for there is a tendency to edema 
and sloughing. The repair of these various structures must be con- 
ducted separately. 

If the tunica vaginalis is opened up and the testicle herniated, it 
must be carefully cleansed and returned and the tunica sutured, 
with or without drainage, depending upon the probabilities of in- 
fection. If the tunica be destroyed, and the testicle remains sound 




tljlZ 



Fig. 84.— Emergency castration. A, transfixion of the cord and ligature of one-half. 
B, ligature carried around the entire cord. {Lejars.) 



it must be preserved, covering it as much as possible with such serous 
covering as remains. Incised wounds of the testicle call for suturing 
of the fibrous coat with catgut. 

The tunica vaginalis is next repaired with a continuous suture 
(Fig. 83), an d finally the scrotal wound is sutured. 

If the testicle is lacerated, or if seen late and manifestly infected, 
it must be removed without delay. Enlarge the wound, exposing 



108 WOUNDS OF SPECIAL REGIONS 

the spermatic cord as high up as possible, and at that level ligate the 
various elements separately and firmly, and resect. Trim away any 
infected tissues in the scrotum and repair, employing drainage 
(Fig. 84). 

Cotton, of Boston (Amer. Jour. Urol., Nov., 1906), describes a 
case of injury to the testicle resulting from a blow on the scrotum by 
a batted base-ball. Shock and excruciating pain ensued, gradu- 
ally subsiding coincident with the development of a large scrotal 
hematoma. 

Operation. The superficial tissues were infiltrated with blood. 
A rent an inch long in the tunica vaginalis. Bleeding from the sper- 
matic artery. The tunica albuginea was torn in shreds, the paren- 
chyma destroyed. "The testis had evidently exploded under the 
swift impact, as a full bladder bursts under a blow." After removal 
of clots and irrigation, the tissues were sewed up layer by layer 
with catgut and without drainage, and light pressure applied. Con- 
valescence uneventful. 



WOUNDS OF THE RECTUM 

Wounds of the rectum are rare. They are usually punctured 
wounds due to falling upon pointed objects, gunshot wounds, or 
tears accompanying fractures of the pelvis. The chief dangers are 
hemorrhage and infection. 

Wounds of this region are usually self-evident, though their extent 
may be a matter of doubt, so that every such injury demands a care- 
ful examination. The examination calls for inspection. To depend 
upon touch alone may lead one into grave error. 

In every, serious injury of this character, anesthetize the patient, 
dilate the anus, and by the use of retractors expose the wound. 
Douche with hot normal salt solution. If the hemorrhage persists, 
the bleeding points are to be clamped with long forceps and an at 
tempt made to suture eh masse, for at that depth it will be hardly 
possible to ligate the vessels. Sometimes in lacerated wounds, the 
oozing can be controlled only by tamponing the rectum firmly, 
packing around a large tube in the center. 

Suturing these wounds is not so desirable as one might at first 






1 



WOUNDS OF THE RECTUM IO9 

think, for the sutures may conduct sepsis to the deeper tissues. Do 
not suture, then, unless the wound is easily accessible, recent and 
clean. If the sutures are used, frequent irrigations of normal salt 
solution must be employed and the bowels kept quiescent for several 
days. 

If the rectal wound has penetrated the peritoneal cavity, which fact 
may develop in course of the examination, or may be suspected from 
J the tympanites and tenderness of the abdomen, the better plan is to 
proceed to a laparotomy. A patient seen recently had lain for two 
months with a low grade of sepsis following a punctured wound of 
the rectum. He recovered promptly after a laparotomy exposed and 
repaired a rectal tear, opening into the pelvic cavity. 

The abdomen is to be opened in the middle line, the patient put in 
the Trendelenburg position, the pelvis cleansed, and the wounds re- 
paired by two tiers of sutures. 

If the small intestine should become herniated through a rectal 
tear, laparotomy is again indicated, reducing the hernia by traction 
from above. If the herniated loop protruding from the anus be 
gangrenous, in order to avoid infection of the peritoneum the affected 
segment should be resected and the two ends temporarily ligated 
before proceeding to the laparotomy. Once the abdomen is opened, 
the two ends of the bowel are to be pulled up and anastomosed. 



CHAPTER XI 
INJURIES TO THE TRUNK 

INJURIES TO THE THORAX 

Certain elementary notions must be clearly comprehended and 
kept in mind in order to make a definite diagnosis of these injuries. 
These notions relate to the anatomy, pathology, and symptomatology 
of the thorax. With respect to the anatomy, one must keep in mind 
the location of the principal vessels of the chest wall and mediastinum; 
the relations of the viscera to the ribs; and the normal areas of reson- 
ance and dullness. In addition, it is necessary to recall the signs and 
significance of the principal primary complications possible in any 
form of serious violence to the thorax, viz. : hemoptysis, hemothorax, 
pneumothorax, emphysema, and hemo-pericardium. 

The various points of anatomy and physical diagnosis, elementary 
though they be, it were perhaps better to enumerate in more detail. 

The principal vessels of the chest wall are the intercostals which, 
protected from injury, lie in the groove in the lower border the rib; 
and the internal mammary iM inches from the sternal border, easily 
reached by a stab. The intercostal may be compressed in the man- 
ner indicated on page 68. If a general anesthetic is necessary for 
another purpose the artery should be exposed and ligated. 

The wounded internal mammary requires ligation and is most 
easily reached through the second or third intercostal space, lying in 
close contact with the pleura. 

The relations of the viscera to the chest wall acquire a special 
significance in connection with traumatism, particularity such per- 
forating wounds as those produced by pointed instruments and the 
bullet. 

Imagine the track of the bullet under a variety of circumstances: 
passing through the right chest antero-posterior, anywhere between 
its apex and the level of the nipple only the lung will be injured; 

no 



HEMOTHORAX III 

below that level, the diaphragm and liver are likely also to be per- 
forated. Outside the nipple the range may be lower and yet escape 
the diaphragm since it slopes from the level of the nipple to the eighth 
rib in the axillary line. 

In the left chest, in the area bounded by the second rib, the ster- 
num, the sixth rib below and the nipple line externally, the heart or 
at least the pericardium is likely to be wounded, and, unless the track 
lies near the sternal line, the lung as well. 

Outside the nipple line and below its level, perforation of the 
stomach may complicate the lung injury. 

Passing transversely through the base of the chest, below the nipple 
line we might expect the wound to traverse successively from the 
right side, the lung, the liver, the stomach, the spleen and the lung 
again. 

The principal primary complications: 

Hemoptysis, following an injury to the thorax, whatever its nature, 
is significant of one thing — -that the lung has been involved. The de- 
gree of injury may be in a manner estimated by the amount of blood 
expectorated. In the dangerous cases, the blood pours from the 
wounded lung tissue into the bronchus and gushes from the mouth. 
In other cases, there is only a slight spitting of blood, leading to the 
belief that the lung has not been seriously torn. It might be mis- 
taken for a hematemesis, but the presence of rales in the bronchus of 
the affected side (or of both) and the light color of the blood and its 
admixture with air, point to the character of the hemorrhage. 

Hemothorax, an accumulation of blood in the pleura, is nearly 
always the result of injury to the lung; although, of course, the in- 
ternal mammary artery or the intercostals may occasionally be the 
source of the extravasation. Gravity determines where the blood 
will accumulate and therefore the patient's position will modify the 
physical signs. 

The symptoms and signs are both modified by the quantity of 
blood and the rapidity with which it is poured into the pleural cavity. 
In the slighter forms, there is scarcely any disturbance of breathing 
and only slight dullness over the base of the lung. 

In the graver forms, the lung is collapsed and crowded toward the 
hilum, so that there are symptoms of asphyxia added to those of in- 



112 INJURIES TO THE TRUNK 

ternal hemorrhage. The face is pale, the skin moist and cold, the 
patient is impelled to sit up and gasps for breath, the pulse is rapid 
and thready, and the patient may thus go on to death. Inspection 
reveals a slightly bulging chest wall; percussion, a complete dull- 
ness, and auscultation, an absence of fremitus and of the vesicular 
murmur. 

Often there is an immediate rise of temperature, due to absorption, 
and which is to be distinguished from the temperature of infection by 
its earlier appearance. 

No attempt to evacuate the extravasated blood is to be made in 
the moderately severe cases; in others, of more urgency, an aspiration 
may give some temporary relief, tiding the patient over a critical 
point. Finally, in rare cases, the magnitude of the hemothorax will 
be such as to demand an immediate intervention, with the purpose in 
view of exposing the lung and repairing the wound in its substance. 
Subsequently, even if the case is mild, infection may occur and is to 
be treated as any other empyema. 

Pneumothorax. — Air may enter the pleural cavity from without 
through an opening in the chest wall, or from within through a 
rupture in the lung tissue. In the first case it enters during in- 
spiration, and in the second, during expiration. 

The physical signs and symptoms grow out of the pressure within 
the pleural cavity and the consequent collapse of the lung. The 
chest wall on the injured side is distended, the intercostal spaces 
bulged out, the viscera are displaced, the ribs motionless, the ves- 
icular murmur absent. If a coin laid on the front of the chest is 
tapped with another coin, the sound will be heard at the back. The 
symptoms are principally those of dyspnea. 

If there are no complications, the air is gradually absorbed and 
the function of the lung restored. 

In extreme cases, puncture will relieve the intrapleural pressure; 
and in the case of a valvular wound in the chest wall, which per- 
mits entrance of the air but not its exit, enlargement of the wound 
is indicated. 

If air and blood accumulate simultaneously — if a herno-penu- 
moihorax exists — the physical signs will be altered, but not the 
symptoms. 



HERNIA OF THE LUNG 113 

Emphysema. — The subcutaneous cellular tissue may become 
charged with air and practically the whole body be involved. It 
is nearly always due in the marked cases to puncture of the lung by 
a broken rib. The air escaping from the lung is prevented, by 
the close contact of the pleural surfaces, from entering the pleural 
cavity, and is forced into the loose tissues of the ruptured chest wall. 

In other rarer cases the inner aspect of the lung is wounded, and 
the air escapes into the tissues of the mediastinum, and follows them 
up into the neck. 

In ordinary cases no treatment is indicated and the air is soon ab- 
sorbed. However, in the severer forms, the symptoms of asphyxia 
and cyanosis may supervene and then free incision over the infiltrated 
zone may be required. 

A man weighing 300 pounds was brought into the City Hospital 
with a crush of the chest, fracturing several ribs. Within a half hour 
after the accident the tissues of his whole chest were inflated and grad- 
ually the emphysema spread till his skin from his face to his feet 
seemed as tight as a drum. His condition was pitiable; his eyes were 
swollen shut, his features livid, and his efforts to breathe distressing. 
An effort was made to strap his chest; morphin and atropin in 
small doses were frequently administered, and the tissues over the 
chest punctured with numerous small trochars which were left in 
situ. In forty-eight hours his pulse and respiration began to im- 
prove and in a few days he was entirely out of danger. 

A case of subcutaneous and mediastinal emphysema of extreme 
gravity was relieved by incising without anesthesia, the skin and 
fascia above the clavicle and dissecting the fascias with finger down 
to the wall of the trachea. A suction apparatus was attached and 
the air escaped in a continuous stream relieving the symptoms rap- 
idly; subsequently a valve drainage of the pleura was established to 
relieve intrathoracic tension and the patient made a smooth recovery. 
(Amer. Jour. Surg., Oct., 1913.) 

Hernia of the lung is a rare complication, and may be immediate or 
secondary. In the first case, the pulmonary tissue is forced through 
the breach in the chest wall by violent expiratory effort. In some 
cases where the skin is not broken, the hernia may be felt as a crepi- 
tant tumor beneath the skin. 
8 



114 INJURIES TO THEjTRUNK 

In the secondary cases, it forms more slowly, and is often due to 
the weakening of the thoracic wall by inflammatory processes. 

Herno-pericardium. — Blood in the pericardial sac follows injury 
to the pericardium. It develops more rapidly and, of course, the 
outlook is much more grave if the heart is also wounded. 

The symptoms are those of syncope induced by the compression 
of the heart by the accumulated fluid; the signs are those of increased 
cardiac dullness. The apex beat is lost, the heart sounds muffled, the 
precordium bulged. It is upon the signs that one must depend for 
the diagnosis, for the symptoms are often complicated by those of 
shock and by those which originate in other injuries in the thoracic 
region. 

To repeat, then, when you reach the patient suffering from some 
form of chest injury, you will observe the character of his respiration 
and his pulse; whether his condition is immediately serious or not is 
to be determined at once by that means. If the circumstances per- 
mit, you will proceed to a systematic examination. Learn from the 
sufferer the location of his pain and the character of his chief distress. 
Note the appearance of the sputum, if there is cough. Inspect the 
chest wall for change in outline and mobility and location of apex 
beat. Determine by percussion the limits of the lung resonance and 
heart dullness; and by auscultation, the presence or absence of the 
vesicular murmur or of rales. 

The case may be so grave that exact diagnosis is unnecessary; or, 
again, it may require the most minute examination and judicious 
weighing of the symptoms and signs to make a correct forecast of the 
eventualities, and to formulate a treatment which will leave nothing 
to regret. 

CONTUSIONS OF THE CHEST 

Simple contusions of the thorax, without fracture of a rib or the 
sternum (which are considered elsewhere) and without symptoms 
pointing to internal injury, need but brief consideration. A hema- 
toma is likely to form. The pain and soreness disappear rapidly in 
the young, but are extremely persistent in the aged and the rheu- 
matic. Strapping and massage with liniment are usually sufficient. 



i 



RUPTURE OF THE LUNG 115 

On the other hand, following simple contusion, there may be a de- 
gree of shock out of all proportion to the trauma. 

A man of thirty, apparently in good health, received a slight blow 
over the chest in a friendly scuffle. The blow was slight, and yet it 
seemed to touch a vital spot and made him gasp for breath. It 
was with difficulty that he reached home and for two weeks he seemed 
upon the verge of a penumonia. A month later he was still unable 
to work and an examination at this time revealed grave organic le- 
sions of the heart. It was greatly dilated and not a single valve 
seemed to be performing its function fully. In spite of rest and treat- 
ment, his condition gradually grew worse, and in six months he died 
with a general anasarca. We must consider that the heart, as well 
as other organs, is liable to contusion and that from such injuries 
acute endocarditis may result. 

In graver contusions, such as crushing injuries, it is rupture of the 
lung which is always to be feared and which is usually evidenced by 
a large hemothorax. It must always be remembered that such an 
injury may occur without fracture of the ribs or sternum. 

Lejars cites the case of a boy eleven years of age, whose chest was 
run over by a wagon. He arose immediately after the accident, but 
fell again unconscious, with blood pouring from mouth and nostrils. 
This hemorrhage did not long persist, but on the fourth day the tem- 
perature rose and he was taken to the hospital. His condition was 
alarming, the pulse weak with a rate of 104, his face cyanosed and 
the dyspnea intense; his heart was displaced to the right, and on the 
left side were the signs of marked hemo-pneumothorax. A puncture 
removing 180 G. of the exudate gave but temporary relief. The 
pulse continued to grow weaker and the dyspnea more intense, and 
an urgent intervention was indicated. The pleura was opened and 
the lung found retracted toward the hilum. In the upper lobe a tear 
was found, 7 cm. long, and running upward, and backward from the 
cardiac incisure. The wound gaped freely. The lung was drawn 
into the opening in the chest wall, and the pulmonary wound repaired 
with five sutures of silk which included considerable tissue to prevent 
their pulling out. The coaptation was perfected by a few superficial 
sutures. The upper lobe was sutured to the parietes and a tam- 
ponade with gauze completed the operation. 



Il6 INJURIES TO THE TRUNK 

The outcome was unfortunate, for death occurred on the second 
day, but the autopsy found the lips of the lung wound well aggluti- 
nated. There was no costal fracture. 

The symptoms of rupture of the lungs are the same whether a rib 
be broken or not: hemo-pneumo thorax, abundant and increasing; a 
spreading emphysema; symptoms of grave anemia; to all these may 
be added more or less quickly, the symptoms of pleural infection. 

The treatment y except in the cases of extreme urgency, must be con- 
servative and expectant. Shock must be combated, the patient 
kept absolutely quiet, and the dyspnea relieved by the sitting posture, 
and, if possible, by inhalations of oxygen. 

The anemia can be relieved by injections of small quantities of nor- 
mal salt solution frequently repeated. 

A puncture will partly empty the pleural cavity, affording great 
relief; and, eventually, the remaining exudate will be absorbed. 

It may happen that after two or three days the symptoms will 
improve. 

But in the worst cases, where the dyspnea is progressive and menac- 
ing, and the heart rapidly growing weaker, the responsibility cannot 
be shifted. It is indicated to operate at once, to open up the thorax 
and repair the tear in the lung, to do an urgent thoracotomy (see 
page 488). 

OPEN WOUNDS OF THE THORAX 

Non-penetrating wounds of the chest wall are of slight significance 
and are to be treated on general principles. 

Penetrating wounds of the thorax derive their significance from the 
particular viscera and vessels which may happen to be involved. On 
the clinical basis, then, these wounds may be divided into three 
classes: 

A. Wounds which involve the pleura or lung. 

B. Wounds which involve the diaphragm. 

C Wounds which involve the pericardium and heart. 

A. WOUNDS OF THE PLEURA AND LUNG 

In whatever manner the wound may be inflicted, there are three 
elements of danger: hemorrhage, asphyxia, and infection. These are 



OPEN WOUNDS OF THE CHEST 117 

the factors which will determine the line of treatment, and without 
some urgent indication from one of these sources the treatment must 
be conservative. There are many things which stand in the way of 
radical procedures such as are employed in the case of abdominal 
wounds. In the first place, the operative technic is difficult; there is 
a marked disturbance of respiration following free access of air to 
the pleural cavity; the exact location of the lung lesion cannot often 
be determined; and, finally, there is always, as Lejars remarks, so 
much guesswork in the prognosis, that we are constrained to give the 
patient the benefit of the doubt and leave the case to take its natural 
course. 

It is best to proceed in this wise: If the case is seen from the first, 
supervise the transportation. Too much importance cannot be at- 
tached to the dangers of rough handling. As has been said elsewhere, 
the nearest shelter is the best. Cut away the clothing, scrub the skin 
adjacent to the wound, and wash out the wound itself with alcohol or 
sterile salt solution. If, on opening the lips of the wound, a bleeding 
point is seen, catch it up and ligate. 

If there is oozing from the depths, it is best to disregard it for the 
present. This constitutes the primary intervention except for such 
suturing as may be required. 

Apply a dressing of sterile gauze, plain or soaked in collodion. 
Cover this with a layer of absorbent cotton and apply a firm bandage 
encircling the whole chest. Place the patient on his back with the 
head and shoulders slightly elevated. Absolutely prohibit conver- 
sation and movement of any kind; and, in the meantime, keep the 
patient under close surveillance. 

In general terms, then, the treatment of any ordinary open wound 
of the chest involving the lung and pleura is to be summed up in two 
words, immediate occlusion and immobilization. 

But there are conditions which demand immediate intervention. 
These are acute anemia or asphyxia, which may follow hemorrhage, 
external or internal; and hernia of the lung. 

External hemorrhage may follow any extensive wound of the chest 
wall, welling up from its depths or flowing by spurts during expiration. 
If there is no hemoptysis, it may be inferred that the lung is not 
wounded; but, in any event, the first treatment must be directed to- 



Il8 INJURIES TO THE TRUNK 

ward the intercostal s and internal mammary. It may be that a tem- 
porary hemostasis will be necessary, and the tamponade described on 
page 68, will be indicated. 

The definite hemostasis requires a free enlargement of the wound. 
If pressure made against the lower border of the rib by an aseptic 
finger introduced through the enlarged wound causes cessation of 
hemorrhage, it is certain that it is an intercostal artery that is at 
fault. It may be difficult to clamp; it may be necessary to resect a 
rib, or to detach the periosteum, which will carry the artery with it 
A curved needle threaded with catgut is then carried around the 
artery. The ligature is tied and the hemorrhage thus controlled. 
The internal mammary may require ligation above and below the 
wound. 

Internal hemorrhage is in every way more serious, for to the anemia 
is added the asphyxia which follows the compression of the lung. 

The patient is pale, anxious, with cold extremities, weak pulse, and 
sighing respiration, the chest wall bulges; the normal resonance and 
vesicular murmur are altered; in short, there are all the signs and 
symptoms of an increasing hemothorax or hemo-pneumothorax. 

But even in the presence of these grave symptoms, it is by no means 
always indicated to operate. One must be content to repair the 
wound, occlude and immobilize, and wait awhile. 

But when the wound is followed by an immediate and complete 
hemothorax, or when the symptoms and signs point to a rapidly ap- 
proaching fatality, one must stand by with folded hands and see the 
end come, or operate; for there is nothing else of any use. An urgent 
thoracotomy must be done. 

Hernia of the lung is rare. The tumor is of variable size and is at 
first crepitant, but rapidly darkens and becomes hepatized. 

The indications for treatment depend upon the time which has 
elapsed and upon the condition of the tumor. If the wound is recent 
and the lung intact, the hernia must be reduced. Begin by a careful 
disinfection of the wound. Cover the tumor with an aseptic com- 
press and tuck its edges under the whole circumference of the wound. 
A steady pressure over the central portion of the tumor will expel the 
air r little by little; and, by reducing its volume, favor the reduction of 
the tumor. 






OPEN WOUNDS OF THE CHEST 1 1 9 

The compress is to be left until the skin wound is partially sutured, 
since by that means one may prevent the sudden pneumothorax 
which sometimes follows reduction. 

If the lung has been wounded, it must be repaired by suture, or by 
ligation and resection before being reduced. 

If some time has elapsed, it is as unsafe to reduce it as to reduce a 
doubtful herniated gut. 

Lejars insists upon resection with the thermocautery. Around the 
base of the tumor pass a ligature threaded on a blunt needle. By 
tying the ligature, a pedicle is formed which is to be amputated with 
the thermocautery. The stump is carefully disinfected and reduced, 
the chest wall repaired, and drainage instituted. 

Finally, in the case where the tumor is already gangrenous and 
sloughing, it is necessary to limit the treatment to antisepsis, leaving 
the slough to detach itself, and happily a cure may follow such spon- 
taneous amputation. 

Axtell reports a case of open wound of the chest which illustrates 
what the doctor's patience and nature's efforts may accomplish in 
conditions apparently most desperate. (American Jour. Surg., 
Feb., 1909). 

A shingle sawyer of twenty-eight, robust and muscular, fell against 
a great circular saw revolving many thousand times per minute. 
Sections of the second, third, fourth, fifth and sixth ribs were cut 
away, these segments varying in length from i inch at the second to 
3 inches at the fourth and fifth ribs. The costal pleura was com- 
pletely destroyed over the seat of the greatest injury. The lung and 
pericardium were exposed. There was one puncture of the lung 
from which the air bubbled and emphysema followed. All the inter- 
costal arteries, veins, and nerves in the injured area were severed. 
The pectoralis major was completely separated from the chest, and a 
part of the pectoralis minor. The wounded man, thrown from the 
saw, fell face downward into a dust pile and the whole exposed sur- 
face of the wound was filled with sawdust and grease. 

He was carried to the hospital and attempt made to repair the 
damage. "Over 450 spiculae of wood fiber were picked out piece by 
piece from the chest cavity and the surface of the lung. Several 
large lumps of greasy dust were removed from the depths of the chest 



120 INJURIES TO THE TRUNK 

cavity." All the ragged edges of the costal pleura, skin, and muscles 
were trimmed away. The jagged and uneven ends of the severed 
ribs were cut off smooth in order to bring the periosteum over them. 
To take the place of the costal pleura destroyed, a flap was stripped 
off the pectoralis major from near its attachment to the humerus; 
left attached near the free end of the divided muscle, it was turned 
forward toward the sternum and sutured to its margin, to the inter- 
costal muscles, and the periosteum of the stumps of the ribs. The 
severed muscles were drawn together by cable sutures and the skin 
flap drawn into place and incompletely sutured. Ample drainage 
was installed. The intervention consumed several hours, something 
like 1 80 sutures and ligatures being required. The emphysema was 
enormous at first, extending from the scalp to the knees, but 
disappeared after forty-eight hours. At the end of six weeks the 
patient had practically recovered without adhesions or restriction of 
the lung. 

B. WOUNDS AT THE BASE OF THE THORAX 

Wounds at the base of the thorax require a separate consideration, 
for the reason that both the thoracic and abdominal cavities may be 
involved through wounds of the diaphragm. 

It must be remembered that the diaphragm corresponds to the Jevel 
of the fifth rib in the right nipple line, and to the level of the sixth rib 
in the left. 

In stab or gunshot wounds, the lung on the one hand, and the 
stomach, intestine, spleen, and liver on the other, may be wounded 
simultaneously; so that, compared with the thoracic wounds just 
considered, those at the base are much more complicated with respect 
to prognosis, diagnosis, and treatment. 

These wounds at the base of the thorax involving the diaphragm, 
will nearly always present an omental hernia. It is often necessary, 
after enlarging the thoracic wound by resecting a rib or forming a 
costal flap, to resect the protruding omentum; and, at the moment of 
reduction of the stump, one may have an unobstructed view of the 
wound in the diaphragm. If blood oozes from it, there is abundant 
evidence of a wound of an abdominal viscus. If there is no bleeding, 
introduce a finger through the opening in the diaphragm and examine 



1 



WOUNDS AT THE BASE OF THE THORAX 121 

the stomach and adjacent structures. If no injury is found, and the 
examining finger is not covered with blood, proceed at once to repair 
the diaphragm. 

A curved needle is best, and interrupted sutures. If there are 
wounds of the abdominal viscera, they may possibly be repaired 
through the phrenic wound; and, in fact, if at all possible, it is the 
method of election. By this route one may readily reach the convex 
surface of the liver on the right side, or on the left the greater curva- 
ture of stomach. 

Still, if the exploration is difficult, if the bleeding is abundant, it is 
better to lose no time, but to do a median laparotomy at once, gaining 
additional room, if necessary, by a transverse incision, following the 
costal arch. Subsequently the wound in the diaphragm may be re- 
paired through the thoracic opening. 

Ludlow, of Cleveland (Annals of Surgery, June, 1905), reports a 
case which illustrates this subject and exemplifiies the treatment in 
general. 

The patient had received two stab wounds in the left side, inflicted 
with a candy maker's knife which had two blades set in a heavy 
handle. One wound entered at the ninth interspace in the axillary 
line, and through it protruded omentum. The blade had entered the 
chest wall obliquely and the skin acted as a valve; but, when the 
skin was retracted, the air rushed in and out of the pleural cavity with 
each respiration. The hemorrhage from the wound was slight. 

The second wound was situated directly below the first in the elev- 
enth interpsace. Omentum protruded from this wound also, and the 
bleeding was slow, but apparently increasing. 

Operation. — Ether anesthesia; a careful cleansing of the field. A 
digital examination revealed the fact that the upper wound, travers- 
ing the pleural cavity without injury to the lung, had perforated the 
diaphragm. The finger passed through these wounds, met the finger 
of the other hand passed through the lower wound, in the abdominal 
cavity. 

The lower wound was enlarged, revealing an active hemorrhage 
from the spleen. The cut surface of the spleen was pulled into the 
wound and a spurting artery clamped. The splenic wound was 



122 INJURIES TO THE TRUNK 

4 cm. in length and extended almost through the substance of the 
organ. 

The cut surfaces were brought into apposition by mattress sutures 
of plain catgut No. 2, on a curved round needle. This controlled 
the hemorrhage. Neither by palpation or inspection could any 
wound of the stomach or intestines be found. The diaphragm was 
then repaired with chromic gut No. 3. The operation was accom- 
plished without the resection of a rib. A small cigarette drain was 
left in both wounds and the external wounds sutured. The week 
following the operation there was some discharge of blood and de- 
bris, but no active hemorrhage. The recovery was uneventful and 
complete. 

Wounds of the diaphragm of whatever form, perforations, or rup- 
tures due to crushing injuries to the chest, are likely to be the site of 
herniae. 

Especially in the latter class of injuries, must one be on his guard 
for this injury* Sometimes there are certain signs which point at 
once to the presence of a diaphragmatic hernia; the displacement of 
the heart, the bulging of the lower intercostal spaces, and the presence 
on auscultation of sounds which in no way resemble the vesicular 
murmur. In these cases, it is best to open up the eighth intercostal 
space and resect the ninth rib, which will usually give a free access 
the site of injury. 

C. WOUNDS OF THE PERICARDIUM AND HEART 

Not every precordial wound will reach the heart. Such a wound 
may be followed only by a slight emphysema and is to be treated by 
aseptic occlusion. 

If the wound has actually penetrated to the heart, death is usually 
so rapid that no measure or relief can be considered. If it is a gun- 
shot wound, death results from shock and hemorrhage; if it is a stab 
or punctured wound, shock plays a very minor part. It is not very 
likely that any small size stab wound of the heart interferes at once 
seriously with the heart's action, unless it involves the " coordination 
center," which, it is claimed, lies in the upper third of the inter-ven- 
tricular groove. 

If the wound in the pericardium be small or valve-like, the blood is 



WOUNDS OF THE HEART 1 23 

retained within the cavity and the constantly increasing intra-peri- 
cardial pressure effects the softer and more yielding of the structures 
within the sac — viz., the pulmonary veins and the descending vena 
cava and the auricles; in this manner, the venous current to the 
auricles is cut off and the agitated heart works to no purpose. The 
sense of oppression, the cyanosis, and venous engorgement all bear 
witness to the compression of the auricles. In the meantime, the 
pulse grows miserably weak and rapid; the apex beat is lost, the heart 
sounds are mufBed, the pericardial dullness is augmented, and the 
thoracic wall bulged. In this manner from " heart tamponade," 
death soon ensues. If the wound in the pericardium is large and the 
pleura opened, the hemorrhage rapidly fills the pleura producing 
hemothorax, scarcely less distressing than the hemo-pericardium. 

If the opening in the thoracic wall is free, the hemorrhage is ex- 
ternal; the blood spurts from the wound or wells up continuously, un- 
controlled by pressure or occlusion, and death ensues from hemor- 
rhage, simply. 

In spite of all this, however, a wound of the heart is not to be con- 
sidered as inevitably fatal and beyond surgical skill. The number of 
reported cases saved by timely intervention is constantly increasing 
and will increase all the more rapidly as time goes by. Any wound of 
the heart sufficiently large to produce hemorrhage, whether external 
or internal, is potentially fatal. 

The only measure of relief is operation. The pericardium is to 
be exposed and opened, the heart relieved of pressure, and the wound 
repaired. 

The question arises as to how late an operation may be undertaken, 
but this cannot be answered by a general formula; as long as there 
is life, there is hope in skillful intervention. In the cases reported, 
the great majority were operated not later than six hours after the 
injury. 

Regarding the location of the wound in the heart, the right and 
left sides are injured with equal frequency, but the ventricles are in 
much greater danger than the auricle in the proportion of seventeen 
to one (Vaughn). The external wound may be located over any 
intercostal space, but the great majority will be found in the fourth, 
fifth, and third in order of frequency. 



124 INJURIES TO THE TRUNK 

Vaughn, who has carefully studied the statistics of operations for 
these injuries, and who reports his second successful case of suture of 
the heart (J. A. M. A., Feb. 6, 1909), offers the following conclusions: 
that there is no longer any question as to the propriety of the opera- 
tion, but that its mortality is probably the same as it was twelve 
years ago when the operation was first introduced. Probably little 
more can be done to prevent death from hemorrhage, but the pre- 
vention of the great cause of death following the operation, infection 
of the pericardium, remains a surgical problem yet to be solved. 
The principles of asepsis and drainage as applied to the operation, are 
yet to be more carefully worked out. 

This summary still holds good at this later date except that ther 
is disposition to extend the indications for operation to those cases 
in which the nature of the wound presupposes heart injury but in 
which the classical symptoms have not yet developed. For it is 
certain that heart "tamponnade" with its concomitant clinical pic- 
ture is often delayed. 

An example is in mind. 

A negro was brought to the City Hospital with a stab wound in the 
fourth intercostal space about halfway between the sternal border 
and the nipple line. His condition was good except that he had oc 
casional slight attacks of dyspnea; pulse 100, respiration 24. In the 
course of two or three hours his symptoms had slightly but percepti- 
bly grown worse. He refused operation. From that time, hour by 
hour the heart dullness increased, the heart sounds altered, the 
radial pulse weakened the dyspnea became more distressing and 
finally after thirty hours he died. 

The autopsy revealed a small wound of the right ventricle. The 
only hemorrhage was within the pericardial sac. 

An operation at the time of admission or a few hours thereafter 
would have been performed under very favorable circumstances and 
almost certainly would have saved the man's life. 

On the other side, Wagner reports a stab case presenting all the 
signs of injury to the heart which an operation proved to be intact, 
although blood had accumulated within and around the pericardium. 
The man would undoubtedly have recovered without operation but 



CONTUSIONS OF THE ABDOMEN 1 25 

the case would have gone on record as one recovering from stab of 
heart under conservative treatment. 

Arx reports a case in which the pain and physical signs pointed to 
injury to the diaphragm and liver, but a laparotomy proved them 
to be intact. The heart was exposed, revealing a hole in the right 
ventricle far under the sternum. When the pericardium was opened 
and the clots released the heart improved at once. In this case the 
heart wound was not sutured but was covered with a strip of gauze 
which was brought out through the closely sutured wound. The 
pulse kept between 80 and 88 and the temperature remained normal. 
Arx remarks that this case emphasizes the value of proper drainage 
(J. A. M. A., Aug., 1913). 

A number of cases of needle punctures of the heart have been 
reported. About 60 per cent, die, the result of intra-pericardial 
hemorrhage occurring within ten days of the accident. 

INJURIES TO THE ABDOMEN 

I. Contusions. II. Wounds. 

I. Contusions of the abdomen occur in many ways; they may be 
the result of severe blows, the kick of a horse, from falls, or from the 
crush of heavy wheels of vehicles. The gravity of such an injury is 
proportionate to the amount of visceral injury, but this is often not 
apparent from the first. 

Whether the viscera are injured or not, there is always some degree 
of shock. In the first hours following the injury, in the doubtful 
cases, the therapeusis must be limited to the treatment of shock. 
If transportation is necessary, it must be done with the greatest care. 

Once the patient is placed in bed, his clothing must be removed, 
his head lowered, the extremities kept warm, and repeated injections 
of normal salt solution or adrenalin made, as the character of the 
shock indicates. 

In the meantime, the case is to be studied and it is to be decided 
whether or not there is a rupture of an organ, or other source of hem- 
orrhage. 

The responsibility is a heavy one, for an internal injury overlooked 
or discovered too late, is likely to result in death. The patient may 



126 INJURIES TO THE TRUNK 

rapidly recover from the shock, but this by no means proves the 
absence of a visceral hurt. 

In the typical case of grave injury, the symptoms of shock are only 
temporarily relieved by the injections; rather, they are shortly re- 
placed by those of internal hemorrhage. The pulse remains small 
and frequent, the skin cold, the face anxious and drawn. The abdo- 
men is distended, and tender to the least pressure, especially in the 
zone of direct injury. There may be dullness in the flanks. There is 
no escape of gas from the bowels, or passage of urine. The patient 
is restless and frequently sighs, and seems to realize his impending 
fate. 

In such a case, the indications are plain. There can be no excuse 
for delay, for awaiting the signs that can only be those of beginning 
peritonitis. Prepare for an immediate laparotomy. 

But suppose the case is not accompanied by the typical symptoms. 
How shall we determine in two or three hours whether or not there is 
a grave lesion? A conclusion must be reached from the study of two 
factors: (a) the pulse, and (b) abdominal tension. 

(a) The pulse, disturbed at first by the shock, rapidly approaches 
the normal perhaps, but within a half hour or sooner, it can be deter- 
mined that it is getting weaker and more rapid. Such a change is 
particularly indicative of hemorrhage. If there is any discrepancy 
between the pulse and temperature, Lejars insists that the former is 
the safer guide, for a subnormal temperature resulting from shock 
may persist long after the other symptoms have disappeared. 

(b) The abdomen may or may not be swollen, but over the site of 
the injury the abdominal muscles soon begin to grow rigid, and resent 
the least touch, under which they may be felt to contract and stiffen. 
This rigidity, localized at first, tends to spread and include the entire 
abdomen. 

The tension is usually augmented by progressive meteorism, which 
is also at first localized, but rapidly becomes general. 

Dullness in the flanks is a valuable sign when present, but its 
absence settles nothing. It may be masked by the distended stom- 
ach and intestine; again the blood may not collect in the iliac fossa, 
but may flow directly into the pelvic cavity, especially if the hemor- 
rhage is on the left side of the mesentery. 



RUPTURE OF THE INTESTINE 1 27 

These modifications of pulse and temperature, of abdominal tender- 
ness and tension, must be taken as sufficient indication for urgent in- 
tervention; for the prognosis does not, in reality, depend more upon 
the nature and multiplicity of the visceral lesions than upon the time 
of intervention, for every hour of delay adds to the chances of infec- 
tion and sepsis — -elements which the early operation may practically 
eliminate. 

Another eventuality: The case is not seen until infection has fixed 
itself upon the peritoneum; the pulse is weak and rapid and progress- 
ively growing worse; the temperature is subnormal, the extremities 
cold; a marked tympanites, with persistent vomiting, perhaps comes 
on. 

Then, indeed, it is late to operate — especially when that means a 
long and tedious laparotomy. Every doctor must answer for him- 
self the question," Is it too late?" As Lejars says, we must extend as 
far as possible the limits of intervention in such cases, for it is the last 
resource; and, even though the mortality is very great, the occasional 
unexpected recovery legitimizes the operation. 

Who has not had his sad experiences with these cases? A single 
example illustrates the subject of intestinal rupture. A laborer roll- 
ing a log off a wagon was struck violently in the abdomen by the end 
of his lever caught by the log as it fell. 

He was unconscious for a moment then arose, vomited once and 
after a little rest to get his breath resumed his labor. 

After an hour or so, however, he decided he had better go home 
as he began to feel some pain in the right iliac region where the blow 
had fallen; six or eight hours later he called his doctor who could 
find no definite indication of any serious lesion, though the pain had 
grown very severe. 

The next morning twenty-four hours later there was some rigidity, 
some tympanites, an increase in the pulse rate, temperature 101, 
complete constipation. 

I saw him some sixty hours after the accident. His aspect was typ- 
ical of peritonitis. He was vomiting bile with a fecal odor. He was 
quite conscious and expressed the opinion that he was done for unless 
surgery held out some hope. 

He lived far out in the country and it was manifest that he would 



128 INJURIES TO THE TRUNK 

not live through the journey to a hospital. His kitchen was hurriedly 
converted into an operating room and a laparotomy performed. It 
revealed two small circular openings in the ileum close to the cecal 
end, a small quantity of the intestinal content free in the cavity anb 
a general peritonitis. 

The whole operation did not last forty minutes but the poor man 
died four hours later. 

It was apparent that he had suffered a contusion of the bowel and 
that subsequently the two small sloughs had occurred and this se- 
quence accounted for the absence of hemorrhage and the small 
escape of intestinal fluids. 

Maurice Kahn emphasizes the necessity of early diagnosis of in- 
testinal rupture and discusses in detail the aids thereto; the part 
which each symptom and sign should have in this determination: 
Shock, pain, tenderness, rigidity, vomiting, circulation, respiration, 
temperature, facial expression, loss of liver dullness. He concludes 
that if we have the persistence for a few hours of the initial symptoms, 
especially of rigidity and pain we are justified even in the absence of 
other symptoms in urging an exploratory operation. (J. A. M. A., 
March 7, 1914.) 

Rupture of the liver in addition to the indications already discussed 
may have some special features. 

In the first place whatever shock there may be is early displaced 
by symptoms of hemorrhage. 

The pulse may be abnormally slow by reason of bile absorption; and 
the pain is definitely localized in the right hypochondrium. 

Much more frequently the tear involves the right lobe. 

Rupture of the spleen produces neither the shock, the abdominal 
tension, nor the early peritonitis which follow rupture of the other 
viscera. Hemorrhage is the main feature and the severity of the 
symptoms are in proportion to the loss of blood and usually this de- 
pends upon the extent of the laceration. However, even a small cut 
at the hilum might produce early and urgent symptoms. (See 
also laparotomy for traumatism.) 

II. Wounds of the A bdomen. ' — Clinically, these fall into two groups, 
(a) those in which there is doubtful perforation of the peritoneum, 

*For gunshot wounds, see pages 151 and 192. 



STAB WOUND OF ABDOMEN 1 29 

and (b) those in which perforation of the peritoneum is quite 
obvious. 

(a) The patient presents himself with a wound of the abdominal 
parietes, of doubtful depth. It is easy to determine, once for all, 
whether the peritoneum has been perforated (and upon that the 
prognosis depends) by passing a probe or grooved director. But one 
should certainly do nothing of the kind. There is a definite mode of 
examination to which one must rigidly adhere. 

Begin by a hurried inquiry into the circumstances of the injury, 
and the character of the weapon. Disinfect the hands for an opera- 
tion. Finally scrub and disinfect the abdominal walls. Not until 
this is completed, is the wound ready to be examined. 

Carefully separate the lips of the wound with finger or retractors; 
and, as you proceed, carefully wipe each layer as it is exposed. If 
necessary to facilitate inspection, enlarge the wound; this will often 
be the case, especially where the vulnerating instrument has entered 
obliquely. 

Dividing the various layers, the peritoneum is reached and found 
intact; there is no oozing from below the level of the muscular layers, 
and, if this finding accords with the other .signs observed, you may 
conclude at once that the wound is non-penetrating. In such a case, 
carefully cleanse the wound and repair each layer separately by con- 
tinuous suture with catgut; the skin with silk or silkworm-gut; 
cover with sterile gauze, a thick layer of absorbent cotton, and a 
firm abdominal binder; and thus have been taken the best steps 
to prevent infection or ventral hernia, which is often the result of 
these wounds. 

If the wound is penetrating, the mode of procedure depends upon 
whether it is (a) a narrow, or (b) a large incised wound. 

(a) A stab wound is the type — -a thrust from a knife, dagger, or 

bayonet. There may be persistent oozing of blood alone, or blood 

mixed with bile and urine, or "food products.'' Such a mixture is 

pathognomonic of visceral injury, but nothing can be decided from 

I its absence. 

The persistent hemorrhage is strongly suggestive of serious injury 
to an organ, especially where it coexists with a fading pulse, pallor, 
tympanites, and rigidity and tenderness of the belly wall; yet the ab- 



130 INJURIES TO THE TRUNK 

sence of all these signs gives no assurance of the absence of a visceral 
injury. 

In any event, then, an explarotory laparotomy is indicated; for only 
by that means can one assure himself of the conditions. Ordinarily, 
the wound itself is enlarged for the purpose of exploration, but in the 
case of more than one wound, or when the abdominal walls are very 
thick, it may be advantageous to resort at once to median laparotomy. 
In either case, the abdominal opening should be large enough for 
rapid work. If the laparotomy is done at the site of the injury, it 
will be wise to disarrange the viscera as little as possible, when spong- 
ing out the exudates. Carefully inspect whatever parts present, and 
often the lesion will be revealed by this first search. 

If a median laparotomy is done, as soon as the cavity is opened 
proceed to the site of the injury; cover the adjacent coils of intestine 
with compresses, thus preventing their possible infection. 

The lesions are only rarely multiple or difficult of repair in this class 
of abdominal injuries. 

(b) Extensive Incised Wounds. — These wounds are produced by in- 
struments with a long cutting edge, or by the ripping cut of small 
knives. Horned animals occasionally produce them. 

The chief characteristic of these wounds is eventration, always 
present in some degree. If the case is seen immediately, the mode of 
procedure is very definite. But only too often the patient's efforts 
have augmented the hernia, or he or his friends have made untimely 
attempts to reduce it. 

Having cleansed the hands and the abdominal walls in the usual 
way, begin next a systematic cleansing of the eventrated mass. 
Cleanse it with warm sterile water, or normal salt solution, rubbing 
gently with the fingers, every inch of the projecting bowel or omen- 
tum. Only in the thoroughness of this step is there any assurance 
of success. If any visceral wounds are discovered in the cleansing 
process, they are to be repaired at this time. 

Once the cleansing and repair are complete, proceed to reduce the 
hernia. The wound may need to be enlarged; if this is necessary, 
slip a finger under an angle of the wound to serve as a guide, and di- 
vide the tissues with scissors. The other angle may be treated in the 
same way. Catch up the peritoneum with forceps along the whole 



STAB WOUND OF ABDOMEN 131 

length of each side of the wound. Now lift on the forceps, and in this 
way create a sort of funnel with smooth sides, over which the bowel 
readily glides in reduction. 

Do not attempt to reduce by rough pressure, which may contuse 
the bowel. If "taxis" fails, there is a method which will surely 
succeed. 

Spread a large compress over the mass; tuck its edges well under 
the entire circumference of the wound; and, with both hands, make a 
gradual pressure on the mass enveloped in the compress, coaxing the 
refractory loops into place with the fingers, and at the same time 
pushing the compress further under the abdominal walls. The 
assistant, in the meantime, lifts up on the forceps attached to the per- 
itoneum, raising the abdominal walls as the hernia recedes. 

When the reduction is complete, leave the compress in place, se- 
cured by forceps until repair of the peritoneum is nearly complete. 
Repair the abdominal wall; begin by suture of the peritoneum with 
small catgut. If the tension is great, it may be necessary to include 
the muscular plane in the suture. Next repair the muscular layers 
separately by continuous chromic gut suture; in the same manner, 
the aponeurosis, and finally the skin, with interrupted silkworm-gut 
sutures. 

A young man was brought to the City Hospital following a passage 
at arms with his prospective father-in-law who had given him the 
coup de grace with a pocket knife. A large part of his bowel he was 
carrying wrapped in his shirt and some towels. He was anesthetized 
and the examination revealed that the eventrated gut was strangu- 
lated, having crowded through a very small peritoneal wound in the 
lower part of the abdomen; but the external wound was extensive 
and the left rectus muscle was completely divided. 

The strangulated loops were patiently sponged, one by one, with 
normal salt solution and the adjacent skin as well. Next the wound 
was enlarged, the strangulation relieved, the bowel reduced and the 
peritoneum repaired. The wound and adjacent skin were next 
sponged with alcohol. 

The ends of the severed rectus were widely separated and were 
with. difficulty brought together by mattress sutures. 

The skin and fascia were repaired without drainage. The patient 



132 



INJURIES TO THE TRUNK 



recovered with no rise of temperature and without the least sign of 
infection. 

Drainage is a question which always arises, but Lejars assures us 
that, if the cleansing is carefully carried out, drainage is in no wise 
necessary. // the case is seen late, but there exist only a few soft ad- 
hesions between the bowel and the walls of the wound, the same dis- 
infection is carried out, the adhesions around the orifice gently 
broken up, and the mass reduced, as before. Drainage is quite 
indispensable, if there are already the signs of a beginning peritonitis. 

If the mass has become the site of a purulent peritonitis, the coils 
agglutinated by false membrane, and gangrenous, there is nothing 
to do except to keep applied moist antiseptic compresses, which 
must be frequently renewed. If the patient survives, whatever 
intervention is needed, may be undertaken later. 






CHAPTER XII 
GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

The care of the wounded in battle has presented in all ages a 
constantly varying problem. Historically speaking, time and place 
and the instruments of war are the elements of the retrospect. 
The character of a particular age is dimly reflected in the character 
of its war wounds, and these regarded as finished products reveal, 
as all things else in Nature, an evolutionary aspect — a gradual 
change from the rudimentary to the complex. 

The cave man, our earliest progenitor, sallied forth to combat 
armed with a shank bone or an unhewn club of oak, his valorous 
purpose to inflict upon his enemy some degree of contusion, the 
simplest form of wounds. 

The very best his efforts might hope for were broken bones, or 
an occasional broken head, and these were the worst the primeval 
surgeon had to manage. At a later stage of civilization the warrior 
had learned how to inflict incised, stab, and punctured wounds. 
Finally, it has remained for our own times to produce the worst 
wounds of all, terrible crushes and lacerations, the product of 
machinery. 

The European War has proven how far the powers of destruction 
are ahead of those that would succor and save. Former wars had 
taught us what the bullet in the fiSld and the bacillus in camp might 
do, and the sanitary service prepared itself to cope with these 
problems, and prepared itself efficiently. But the unexampled loss 
of life and limb along the Marne, the Yser and the Vistula, and on a 
hundred other battlefields, left the Medical Department almost 
helpless with yet new problems to solve — problems for the most part 
unsolvable. 

The artillery aided by the aeroplane have made it almost im- 
possible to give the wounded adequate First Aid and the first aid 

*33 



134 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 



Martini-Henry 



Guedes Lee-Metford Mauser Krag-Jorgensea 




Fig. 86. — The distinguishing feature of the rifle is the spiral grooving which gives the 
projectile a rotary movement, maintained throughout its flight and which lessens its 
tendency to depart from the straight line. The various rifles differ with respect to the 
number of grooves, their depth and the angle they make with the bore. The Martini- 
Henry represents the first form of the modern Breech loading gun — 0.45 caliber conical leaden 
bullet weighing 450 grains. The barrel rifled with 7 grooves, with one turn in 22 inches. 

The later rifles have smaller bores, fewer grooves; the trajectory is less, the initial velocity 
and the range much greater; the steel jacketing diminishing deformation. 

Lee-Metford bullet, caliber 0.303, one turn to 10 inches of rifling. 

The Krag-Jorgensen, caliber 0.315, initial velocity 2034 feet per second and sighted for 
2078 yards. 

The Mauser, caliber 0.311, weight of bullet 154 grains, velocity 2882, range 2187 yards. 

The U. S. Springfield, caliber 0.300, weight 150 grains, velocity 2600 and range 2850 yards. 



THE ARMY BULLET 



135 



dressing, which the wounded or his comrade may apply, has proven 
inadequate for the tremendous lacerations of bursting bombs. 

Every factor, it would seem, conspired to make wound infection 
the great surgical feature of this war. The character of the wounds, 
the lack of First Aid, the delay in evacuating the wounded and the 
slowness of transportation combined to give the pus, the tetanus, 
and the gas bacillus a temporary triumph over the earnest devotion 
of the highest surgical skill. To meet these conditions the efforts 
of the sanitary service in the future must be directed. 

Under what may be called the normal circumstances of war the 
army bullet wound still maintains the characteristics we have ascribed 
to it for the last twenty years. These wounds vary in severity from 
mere contusions through all the grades of injury to destructive lacera- 
tions, depending upon the range. If the gunshot wounds in military 




Fig. 87. — Gold coins struck by a bullet fired point blank at a Belgian who carried the 
coins in his belt. He was stunned by the impact and left for dead. The condition of the 
coins indicates the force of the bullet and its tendency to deflect. {Peacock, Brit. Jour. 
Surg., Jan., 1015.) 



practice differ from those seen -in civil practice with respect to 
character, prognosis and treatment it is because the bullets in 
each case differ with respect to hardness, range and initial velocity 
and because the wounds are produced in different environments. 

The modern army bullet (Fig. 86) is of small caliber, is jacketed 
with steel, has a very high initial velocity and, as compared with the 
older missile, a remarkable range. 

The small, sharp-pointed bullet, used by most of the combatants 
in the European War, produces some effects differing from those 



136 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 



produced by the bullets with conical tip. These results are base< 
on its instability of flight. Its perforating power is immense, yet 
unless it strikes squarely on the point it is most easily deflected 
(Fig. 87). At the moment of oblique impact it acquires a new move- 
ment, viz., a revolution on an axis transverse to the line of flight. In 




Fig. 88. — Showing wound of entrance at 
close range with explosive effect. (Tuffier, 
Brit. Jour. Surg., Jan., 19 15.) 



Fig. 89. — Same, showing wound of exit. 
Note tremendous laceration. (Tuffier, Brit. 
Jour. Surg., Jan., 19 15.) 



other words, the bullet moves forward like a wheel. According to 
Makins, if the velocity at moment of impact is not great it may make 
several turns in the tissues. If the velocity is still considerable it 
may turn end for end merely, or it may remain vertical to its path, 
making only a half turn. In all these cases it retains to the last the 
spin on its long axis, imparted by the rifling of the gun. 



; 



BULLET WOUNDS OF SKIN 137 

At very close range all these bullets are tremendously destructive 
to all the tissues alike. 

At long range the conical bullet tends merely to perforate, whereas 
the pointed bullet, for the reason given above, tends to tear through 
the tissues in any other position than point first, unless striking 




Fig. 90. — Showing small entrance wound at long range; large irregular wound of exit. 

(Makins.) 

squarely. In this manner, even at long range, explosive effects may 
be produced. However, at medium or long range the various tissues 
present certain general characteristics. 

The skin presents a wound of entrance smaller than the bullet 
and likely to be dirty and discolored. The wound of exit, if present, 
is larger, more irregular and bleeds more freely (Figs. 88, 89 and 



138 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 



90). The pain in flesh wounds is often moderate, usually a burning 
sensation, and the shock is not severe. 

The fascia presents a smaller opening than the skin and is likely 
to be slit rather than cut in twain and so tends to close the wound, 
oftentimes materially interfering with drainage. 

The muscles are contused and lacerated, often infiltrated with 

blood — conditions favorable to infection. 
The tendons are often pushed aside and 
thus escape serious injury. At other times 
they are partly or wholly divided — condi- 
tions to be considered in the course of 
surgical repair. 

The blood vessels may be pushed aside 
but ordinarily do not escape if in the 
bullet's track, so that one of the frequent 
causes of immediate death is hemorrhage. 
Yet even in the case of laceration of the 
larger arteries, spontaneous arrest of bleed- 
ing may occur. 

Contusion of the blood vessel results in 
aneurism, the first indication of which is 
the murmur (Fig. 91). The subsequent 
character depends on whether or not in- 
fection occurs. Heyrovsky has specially 
studied these injuries and points out the 
dangers, which are secondary hemorrhage, 
gangrene, and the late hemorrhage following prolonged suppuration. 
Primary gangrene is most often seen in wounds of the popliteal, 
and the gangrene sequent to these injuries is of the moist variety. 

In the non-infected case, secondary hemorrhage may occur as 
late as the third week. The vessel in such cases is to be ligated at 
the site of injury and not at the point of election. The injured 
vessel is exposed and followed up to healthy tissue and no higher 
and then ligated, the wound to be left open and without tamponade. 
Following this method not a single case required amputation. Of 
twenty-one infected cases three died, the result of ascending throm- 
bosis, and five more were cured only after amputation. 




Fig. 91. — Traumatic aneurism 
gunshot wound. (Moullin.) 



BULLET WOUNDS OF NERVES 



139 



The mortality of all cases of secondary hemorrhage was 14.2 per 
cent, as compared with 81.4 per cent, statistics of Billroth in 1870. 
(Wiener Klin. Wochenschrift, Feb. 11, 1915-) 

The nerves, like the tendons and blood vessels, may be pushed 
aside, but are more likely to be contused or divided, resulting in 
paralysis — immediate or remote — neuralgia or trophic disturbances, 
such as wasting or contractures of the muscles, or degeneration or 
inflammation of the skin corresponding to the distribution of the 
injured nerve. Even though the nerve itself is not directly injured, 
these conditions may later result from its inclusion in scar tissue. 
It is often necessary to expose the nerve in order to clear it of 
exudates and debris, or to attempt to suture. 





p IG- 92- — Types of fracture of long bones. (Makins.) (a) Primary lines of stellate 
fracture; (b) stellate on one side, transverse on the other; (c) complete wedge broken out; (d) 
incomplete wedge; (e) oblique fracture. 

Gosset calls particular attention to the musculo-spiral in this 
connection and emphasizes the value of exposing it throughout its 
whole course down the arm. He employs for this purpose an 
oblique incision extending from the level of the axillary border 
behind to the front of the external condyle, the arm held vertically 
and the elbow flexed, the hand near the face. Division of the fascia 
and separation of the muscles readily exposes the nerve, which lies 
in close contact with the bone throughout its course. The results 
have been such as to encourage this procedure in every case of 
injury with symptoms of nerve involvement. (La Presse Medical, 
Jan. 21, 1915.) 



140 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 






Bone presents a wide variation in the character of the lesions 
produced. There may be mere puncture, there may be extensive 
comminution, or any grade of injury between these two extremes 
(Figs. 92, 93). 

The character of the injury will depend upon two factors: (a) 
the character of the bone and (b) the range of the bullet. 





Fig. 93- — Perforation of the^great trochanter, without comminution. Bullet fired 
long range lodging in cancellous'tissue. Note position of bullet. Bullet was not remove 
(Harris, Brit. Jour. Surg., Jan., 1915.) 



(a) If the bone is soft and cancellous, the tendency is toward 
perforation; if it is hard and compact, the tendency is toward 
comminution. 

The articular end of the long bones, the short, and the irregular 
bones are likely to be merely perforated. On the other hand, the 
shaft of the long bones, the skull, the scapula are much more likely 
to be shattered. 

(b) At long range, perforation is rather to be expected; at very 
close range, comminution is the rule. 



GUNSHOT FRACTURES 



141 



So far as the long bones are concerned, if transverse fracture 
occurs, its tendency is to stop short of the articulation (Fig. 95). 
With respect to the bones of the limbs, it is to be noted that the 




FlG# 94# — Comminuted fracture of the femur. Bullet lodged in soft parts. (Harris, 

Brit. Jour. Surg., Jan., ioiS) 

exit wound will be the more comminuted (Fig. 96). Perforating 
fractures without solution of continuity are often difficult of diag- 
nosis, because of the absence of characteristic symptoms. The 



142 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 




Fig. 95— Lower end of femur, showing tendency of fissures to stop short of articular ends. 

(Makins.) 




Fig. 06. — Small wound of entrance and large wound of exit on left leg. Fragments of 
bone carried across to right leg producing large laceration, requiring amputation. (Makins.) 



GUNSHOT FRACTURES 



143 




Fig. 97. — Oblique perforation, implicating both epiphysis and diaphysis, 
with large fragment at exit. (Makins.) 




Fig. 98. — Transverse section of "gutter" fracture. (A) No loss of substance; 
(B) comminution. (Makins.) 



144 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

diagnosis is to be made by reference to the track of the bullet, 
by palpation, and from presence of bone dust in the wound of exit, 
etc. (Fig. 97). 

Comminuted fractures present an excessive mobility, and often 
crepitus is hard to elicit. Owing to " local shock," the limb may 
be quite powerless and yet painless. 




Pig. 99. — Gutter fracture perforating skull in the center of its course. (Makins.) 

Primary shortening is often absent by reason of the muscular 
relaxation due to shock. Even though healing takes place un- 
eventfully, a large amount of callus is likely to be thrown out and, 
for a long time, the union will not be strong. 

Acute osteomyelitis may follow infection. On the other hand, 
necrosis may occur late and after the wound has apparently quite 
closed. 

In the bones of the skull is frequently seen the so-called " gutter 
fracture," in which there are usually two apertures in the scalp. 



BULLET WOUNDS OF THE CRANIUM 145 

connected by a trench ploughed through the outer table and diploe 
(Figs. 98 and 99). 

The corresponding part of the inner table is comminuted ex- 
tensively and perhaps depressed. 

The length of the gutter depends upon the surface curvature, and 
the antero-posterior are more serious, as a rule, than the transverse 
(Fig. 100). 

The joints present effects peculiarly variant: the capsule alone 
may be injured; the articular ends of the bones may be guttered or 




Fig. 100. — Superficial perforating fracture; roof lifted at both openings. (Makins.) 

penetrated with or without injury to the capsule; there may be 
much shattering, fissures radiating in all directions; or the joint may 
be involved by extension from the wound of the shaft. The bullet 
may be retained in the joint cavity. Effusion into the joint is a 
constant symptom following perforation — a mixture of blood and 
synovial fluid. 

Of the great cavities and viscera, each has its own particular 
symptomatology. 

The cranium, according to Von Bergman, presents the following 
lesions: At short range, the skull and scalp are torn to pieces; at 
160 feet, the scalp is preserved but the skull is shattered; there are 
10 



146 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

two openings with lacerated edges with brain exudate, the wound 
exit always larger than that of entrance. 

At 320 feet, there are two openings, each surrounded by a series 
of concentric fissures in addition to radiating fissures (Fig. 101). 

At 4000 feet, the radiating fissures still appear. 

At 5600 feet, entrance and exit wounds are clean-cut holes. 




Fig. ioi. — Extensively comminuted gunshot fracture, bullet fired at close range. (Senn 

after Von Bergman.) 



At 8000 feet, there is only the wound of entrance, and the bullet 
lodges in the brain. The injuries to the dura mater are analogous to 
those of the skull. 

The brain itself, semifluid, is torn to pieces at short range, through 
hydrodynamic action. At long range, the bullet merely traverses 
the brain, producing areas of contusion in the neighborhood of its 
track. There may be a diffuse hemorrhage throughout the brain, 
the ventricles being filled with blood. 



BULLET WOUNDS OF THE CRANIUM 147 

The symptoms are such as belong to concussion, compression, 
contusion, or laceration in general. 

Thus following these various degrees of brain injury there occur 
more or less marked indications of the loss of brain function, both 
general and focal. 

Most prominent are motor and sensory paralysis; impairment 
of the special senses, especially sight and hearing; aphasias and 
amnesia — all these in various combinations. 

These symptoms usually emanate from the regions adjacent to 
the track of the bullet, though occasionally it is evident that outlying 
portions of the brain have suffered as well. 

The amount of damage which the brain may suffer with practical 
recovery is often astounding. Sometimes it would seem that it is 
merely a matter of controlling pressure and infection. 

As illustrating this point we may instance some of the case reports 
of Whitehorne-Cole in service at one of the British evacuation 
hospitals in France. 

Case i. — Compound comminuted fracture of skull from a shrap- 
nell bullet. Longitudinal sinus along vertex of the skull, and the 
brain substance much lacerated. Trephining, debridement, disin- 
fection. Eighth day afterward, mental condition good. Partial 
motor paralysis. At end of month, paralysis greatly improved, sent 
home practically well. 

Case 2. — Compound comminuted fracture of skull from rifle 
bullet through both parietals. Septic. Aphasia, right hemiplegia. 
Disinfection. Drainage. 

First day after operation: Aphasia, hemiplegia, urinary incon- 
tinence. 

Fourth day: General condition much improved. Hernia of the 
brain with some oozing of its substance. Alcohol pack applied. 

Sixteenth day: Hernia practically gone. 

One month: Wound healed; aphasia gone; hemiplegia much 
improved; can read and talk and walk; sent home. 

Case 3. — Compound comminuted fracture of skull; rifle bullet 
through left frontal and temporal region. Left facial paralysis. 
Whole track of bullet laid open. Removal of fragments. 

Three weeks after: Wound healed and paralysis gone. 



148 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

Case 4. — Compound comminuted fracture of right parietal. 
Hernia of brain; left hemiplegia. 

Three weeks later: Well except for slight paralysis in left arm. 

Case 5. — Compound comminuted through orbital region. Left 
eyeball collapsed. Hernia cerebri. Both wounds septic. 




Fig. 102. — Shrapnel bullet lodged in body of the vertebra. Symptoms of concussion; 
complete recovery. (Harris, Brit. Jour. Surg., Jan., 1915.) 



Did remarkably well after operation until fifth day, when pulse 
and temperature began to rise. Shortly afterward followed by 
death. 

There was an enormous amount of bone and brain destruction, 
and that he should have done so well for five days is very remark- 
able. (Lancet, March 13, 1915.) 

The spine is seriously injured in proportion as the cord suffers 






BULLET WOUNDS OF THE THORAX 149 

(Fig. 102). Aside from the cases in which the cord lies in the track 
of the bullet and is partially or completely divided transversely, 
there are those cases in which there is no anatomical lesion of the 
cord, perhaps nothing more than perforation of a vertebra, yet the 
functions of the cord are markedly depressed. Absence of deep 
reflexes must not be taken to indicate complete rupture of the cord. 
This may be due to " concussion" of the cord, which Makins de- 
scribes in detail. 

The degree of concussion, and therefore the degree of functional 
depression, depends directly upon the velocity of the ball. 

In slight spinal concussion, the symptoms consist in loss of 
cutaneous sensibility, motor paralysis, and vesical and rectal in- 
competence, persisting for a few hours or even two or three days. 

Recovery begins with return of sensation, often modified, followed 
later by return of motor activity. 

"Severe concussion, contusion or medullary laceration, may be 
considered as lesions of equal degree as to severity, bad prognosis, 
and unsuitability for active interference; all characterized by the 
same essential phenomena, viz.: symmetrical abolition of sensation 
and motility, absence of any sign of irritation in the paralyzed area, 
and loss of patellar reflex. These severe injuries are all accompanied 
by profound shock. The patient lies still, with eyes closed, great 
pallor of surface, the sensorium benumbed, the pulse small and 
irregular, respiration shallow" (Makins). 

In addition to these lesions there are such as arise from com- 
pression, either from bone or from a lodged bullet. But, as Makins 
says, it may be assumed that a bullet injuring the vertebra suffi- 
ciently to displace bone, has, at the same time, produced grave 
lesions of the cord. If the pressure is due to the bullet, it argues 
that its velocity was low and that there may be no serious lesion of 
the cord and that the symptoms are those of compression alone. 
Compression due to extra-dural hemorrhage can rarely produce 
serious symptoms. 

The thorax may or may not be penetrated by the impact of a 
bullet, though penetration, of course, is the rule, and these wounds 
constitute a large part of the casualties of battle. The non-penetrat- 
ing wounds present no features of especial interest. The skin and 



150 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

muscles may be injured in various degrees between simple perfora- 
tion and serious laceration. The clavicle and scapula may be 
fractured; the axillary space may be involved, with serious results. 

The penetrating wounds cross the thorax in every direction, 
transversely, longitudinally, and obliquely. 

Those which traverse the thorax longitudinally, and are received 
while firing or advancing in the prone position, are noteworthy in 
that the abdominal cavity is usually also involved. The abdominal 
cavity is also likely to be penetrated when the base of the thorax is 
crossed. 

If a rib is involved, the bone injury is usually limited, and these 
fractures are considered of importance only when the intercostal 
artery is wounded. In many of these fractures from the army bullet 
the ordinary symptoms are absent, either because of the localized 
character of the injury and absence of contusion of the soft parts, or 
because the fragmentation in the track of the bullet is so complete 
as to preclude crepitus. 

The lungs , almost certain to be involved in perforating wounds of 
the chest, escape with remarkably slight damage, owing to their 
elasticity. 

Those bullets which pass near the root of the lungs are very likely 
to involve the great vessels, followed by rapid and fatal internal 
hemorrhage. 

Certain symptoms manifest themselves in most cases of lung 
injury in some degree. Shock, if it exists at all, is not usually 
serious and arises rather from the injury to the chest wall; nor are 
pain and dyspnea prominent. 

Hemoptysis is fairly constant, but not persistent longer than two 
or three days. Cough is seldom troublesome and pneumothorax is 
rare. 

Hemothorax is very frequent, but in the great majority of cases is 
due to hemorrhage from the chest walls — to the intercostals rather 
than to the lung injury. 

Tuffier remarks of these cases as observed in the French field and 
base hospitals that bullet wounds of the chest — such as reach the 
hospital — are generally remarkably mild and cases of hemothorax 
requiring intervention are quite exceptional. 



BULLET WOUNDS OF THE THORAX j 151 

From one of the field hospitals comes this report which is typical: 
"Cases 4, s, 6 — perforating bullet wound of the chest. These cases 
were of comparatively benign character. Each showed the following 
signs and symptoms: pain, dyspnea, slight hemoptysis, immobility 
of one side of the chest and signs of free fluid in the base. They all 
did well during their stay with us. 

Case 7. — Perforating chest wound of more serious character. In 
this case the right hemothorax showed rapid increase of the fluid 
with displacement of the heart and urgent dyspnea. We tapped the 
chest drawing off 3 pints of blood-stained fluid. Two days later 
there were signs of air in the pleura, but after a second tapping, 
which drew off air and pus, the patient made a sufficient recovery to 
be moved" (British Journal of Surgery, Jan., 1915). 

The symptoms of a hemothorax reach their full height on the third 
or fourth day. The pain is severe, the pulse and temperature rise, 
dyspnea is prominent, respiratory movement on the affected side is 
annulled, and there are the physical signs of fluid on the pleura. 

The course of the temperature is a matter of concern, for the fever 
suggests empyema. It seems always to rise pari passu with the 
increase of blood in the pleural cavity, often declining after the 
third or fourth day, always falling after a paracentesis and rising 
anew with fresh access of pleural hemorrhage. On the other hand, 
the fever of infection arises later, persists, or gradually mounts 
higher. 

Perforating wounds of the heart in warfare Makin regards as 
certainly fatal, believing that the cause of death is not hemorrhage, 
but sudden stoppage of the heart action. 

Senn believes that death usually occurs from compression of the 
heart, due to hemorrhage within the pericardium. In those cases 
where, from the anatomical features, the heart would seem to 
be involved and yet presents no symptoms of injury, the inference 
must be that it escaped, owing to change in position and size 
incident to contraction. 

Other observers write that a bullet has been known to pass through 
the heart without fatal effect. 

Penetrating wounds of the abdomen are seldom simple in character, 
for it only rarely happens that a single viscus is involved. The one 



152 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

symptom which, if it occurs at all, is common to wounds of all 
abdominal organs, is peritonitis. The sources of hemorrhage are 
numerous. The degree of injury to every organ decreases with 
increased range. The small intestine is naturally the structure most 




Fig. 103. — Perforating wounds of small intestine, (a) Entry; (b) exit. Note slit-like 
character and eversion of mucous membrane; localized ecchymosis more abundant around 
exit aperture. (Makins, from St. Thomas Hospital Museum.) 

frequently wounded and, of course, its perforations are multiple 
(Fig. 103). 

Pain, collapse, vomiting, and peritonitis are nearly always present, 
although present also in wounds of the stomach and large intestine. 
The peritonitis is more widespread in the case of the small intestine 



TREATMENT OF BULLET WOUNDS 153 

than in the case of the stomach and large intestine, because of the 
greater activity and motility of the small intestine. Vomiting of 
blood may be taken to indicate perforation of the stomach. The 
stomach and intestines escape " explosive " effects in proportion as 
they are empty at the time of injury. 

The bladder when wounded may present two openings; both may 
be extra-peritoneal, both may be intra-peritoneal, or one may be 
intra- and the other extra-peritoneal. An extra-peritoneal wound 
bleeds the more profusely; an intra-peritoneal wound permits the 
escape of urine into the peritoneal cavity. Hematuria, or suppressed 
urination with an empty bladder, points to the character of the 
injury. 

The liver is likely to be simply perforated or notched, though at 
close range "explosive" effects are observed. The chief result is 
hemorrhage and, in some cases, an escape of bile, due to injury to the 
gall-bladder or the bile ducts. 

The spleen if merely perforated gives rise to hemorrhage, usually 
insignificant, unless its main vessels are involved. 

The kidneys give rise to either extra- or intra-peritoneal hemor- 
rhage, which is not serious unless the perforation involves the 
hilum. Shock is nearly always present as well as hematuria and 
frequent urination. 

The pancreas: there is no way by which injury to the pancreas 
may be diagnosed. It may be merely inferred from the course of 
the bullet. It is so situated that it cannot be reached by a bullet 
without injury to other organs more likely to give due notice of their 
affront. 

PROGNOSIS AND TREATMENT 

Flesh wounds produced by the army bullet and uncomplicated 
by infection tend to heal without difficulty. Whether or not in- 
fection occurs depends upon the efficiency of the first-aid dressing — 
that is to say whether it is ample and whether it is applied in due 
time. 

The aim of the first dressing is to secure aseptic occlusion but if 
the wound is exposed to infection from sources other than the bullet 



154 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

before the dressing is employed, the wound may as well be regarded 
as infected. 

Again if the wound is large and lacerated, even if the dressing is 
applied at once, infection is almost certain to occur. Consequently 
some form of antiseptic treatment is to be carried out in these cases. 
This will ordinarily be done at the field hospital. 

Many observers in the European War condemn the use of iodine, 
asserting that it does not agree with these wounds, tending to 
produce irritation, inflammation, or even sloughing of the parts. 
If these effects occur, however, it is probably not the fault of the 
remedy but rather the fault of the user. If the iodine solution is 
poured into an open vessel, the alcohol evaporates, the solution 
becomes more and more concentrated and of such strength as 
finally to be noxious to the tissues. Alcohol and iodine will probably 
remain for some time to come the antiseptic agents most available 
for such work. 

In the base hospital the treatment of the wound which has become 
septic presents a different problem. A larger choice of antiseptics 
is here permissible. It is evident from the many reports on this 
subject that the ideal antisepsis for extensive suppurations has not 
yet been found. 

Carbolic acid, bichloride of mercury, peroxide of hydrogen, 
boracic acid — each of a long list of germicides — has its special 
indications. A solution of i to 100,000 nitrate of silver has been 
highly recommended. Oftentimes it is indicated to enlarge the 
wound and search for a piece of the clothing or other foreign body, 
though it is unnecessary to say that no such search should be carried 
out unless sepsis supervenes. Under no circumstances is the bullet 
to be probed for. In prolonged suppurations the use of vaccines will 
often be found useful. In the case of the limbs, these bullet wounds 
of the soft parts, even as in the case of shell wounds, may call for 
primary amputation when the blood supply is compromised beyond 
the hope that a collateral circulation may be established. Skene 
recommends in the case of large suppurating areas that antiseptic 
sawdust be used. The affected area is covered with a gauze sheet, 
the sawdust poured on and the edges of the gauze folded over to 
hold the dressing, the whole to be changed every two or three hours. 



TREATMENT OF GUNSHOT FRACTURES 



155 



Finally, tetanus or the gas bacillus infection may supervene, each 
requiring its special treatment. (See page 285.) 

TREATMENT OF GUNSHOT FRACTURES OF THE LONG 

BONES 

The treatment of gunshot fracture of the long bones varies in 
detail, depending upon the character of the injury to the bone and 





Fig. 104. — Simple perforating frac- Fig. 105. — Extensive comminution with 

ture of the lower end of the tibia, moderate injury to the soft parts. {Harris, 
(Makins.) Brit. Jour. Surg., Jan., 1915.) 

to the soft parts. On this basis, three clinical varieties may be 
recognized: (a) Simple perforating fracture (Fig. 104); (b) ex- 
tensive comminution with moderate injury to the soft parts (Fig. 
io 5); ( c ) extensive comminution with great laceration and de- 
struction of the soft parts (Fig. 106). 



156 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

(a) The treatment of uncomplicated perforating fracture is 
exceedingly simple: Aseptic occlusion and immobilization and, 
provided only that infection is kept out of the wound, the results are 
uniformly excellent. 

(b) In this case, conservatism is still the better course; the wound 
in the soft parts is cleansed and dressed, the bones adjusted and an 




Fig. 106. — Extensive comminution with great laceration of the soft parts, requiring 
amputation. (Harris, Brit. Jour. Surg., Jan., 1915.) 

emergency splint applied until such time as the more definite treat- 
ment can be instituted. 

(c) In case the bones are shattered, the soft parts reduced to 
pulp, it is better to proceed to immediate amputation. It is under 
these circumstances that Fitz Maurice Kelley recommends the 
simple circular amputation of the member, dividing all the tissues 
at the same level, making no effort to fashion a flap. After the 
dangers of infection are passed, another amputation following the 
usual lines is to be practised. 



TREATMENT OF GUNSHOT FRACTURES 1 57 

The question of immobilization is complex. On the field shaped 
splints of zinc or molded wire splints may be employed. Tuffier, 
however, expresses preference for the wooden splint fashioned and 
padded in the ordinary way. He praises its simplicity and efficiency . 
At the field and base hospitals no such simple routine can be followed 
and each case must be treated according to its character, taking into 
account the degree of fragmentation, the tendency to displacement, 
the requirements of frequent change of dressing of the soft parts and 
the comfort of the patient. 

In the ordinary fracture, with absence of wound infection, the 
plaster splint remains the dressing of choice. 

In the case of the greatly comminuted fracture with serious sup- 
purations to be treated, the problem of maintaining coaptation 
while handling the limb in doing the dressings is one difficult to solve. 

E. W. Hey Groves, in the British Journal of Surgery (Jan., 1915), 
has pointed out the value of continuous extension in this class of cases 
and the manner in which the principle may be applied to the indivi- 
dual fractures. Two methods he holds in reserve: first, extension 
splints, modifications of those invented by Borchgevrink; second, 
transfixion apparatus. 

The splint for the humerus is a Y-shaped wooden piece, the crutch 
padded for the axilla and the end extending beyond the elbow and 
fitted with a pulley wheel. A stirrup of adhesive plaster is fixed to 
the lower part of the arm and a perforated wooden bar fitted into the 
stirrup. The splint is now adjusted to the axilla and inner aspect 
of the arm and fixed with adhesive strips. A cord, attached to the 
wooden stirrup, is passed through the pulley and brought around to 
the inner surface of the splint where it is fastened with whatever 
tension may be desired. 

Groves fastens the pulley cord to a solid rubber band arranged as 
a loop on the inner side of the splint, to perfect the continuous 
extension. 

When the danger of infection does not contra-indicate, he applies 
the double transfixion apparatus pictured in connection with the 
femur (Fig. 113). 

The upper end of the humerus is transfixed at a point in the line 
between the inner and outer border of the arm, and at the level just 



158 



GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 






below the middle of the deltoid, avoiding the cephalic vein and the 
circumflex nerve. 

The lower pin is passed through the humerus from side to side, 




Fig. 107. — Posterior angular splint for forearm with full supination. Note manner 
in which the extension cord passes through the pulley and to the rubber bands on back of 
splint. {Groves, Brit. Jour. Surg., Jan., 1015-) 

JH2 inch above the epicondyles. Before the lower pin is passed, 
a perforated iron hoop is adjusted over the elbow and the pin 
passed through the proper perforations to hold the hoop in position. 




Pig. 108. — Antero-internal splint for forearm, when the elbow and ulna are involved 
Note the position of the rubber bands on internal surface to which the extension cord is 
attached. {Groves, Brit. Jour. Surg., Jan. 1915.) 

Extension bars are now fitted to the transfixion pin above and to the 
hoop below. The screws of the extension bars permit of powerful 
extension, correction of lateral angulation and rotation, and ready 



TREATMENT OF GUNSHOT FRACTURES 



159 




Fig. 109. — Antero-internal splint applied to patient in the 2nd Southern General Hospital, 
with fracture of the ulna. (Groves, Brit. Jour. Surg., Jan., 1915.) 




1 Fig. no. — Radiogram of elbow shown in Fig. no. Note that the head of the radius is in 
good position as a result of the extension. (Groves, Brit. Jour. Surg., Jan., 1915.) 



l6o GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

access of wounds. Of course the sepsis connected with the trans- 
fixion pins is the objection to this method to be overcome. 

In the case of the forearm a posterior angular splint is recom- 
mended, applying the same principle of extension as in the case of 
the humerus. The extension, in the form of an adhesive plaster 
stirrup, is attached to the forearm and by means of cord and pulley 




Fig. hi. — Antero-internal splint applied to fractures above and below elbow. The splint 
with extension reduces both fractures. {Groves, Brit. Jour. Surg., Jan., 1915.) 



the traction is exerted on the forearm, the arm being fixed to the 
upright piece of the splint. The cord is attached to an elastic 
rubber band on the back of the forearm piece (Fig. 107). The 
forearm is thus fixed in complete supination. 

In case of a wound on the back of the member, it may be neces- 
sary to employ a metal frame splint with two lateral bars for the 
forearm, the extension being applied in the same manner. 



TREATMENT OF GUNSHOT FRACTURES 



161 



In case the elbow is involved with comminution of the ulna and 
laceration of the forearm, an antero-internal splint is recommended 
(Fig. 108), leaving the whole outer and posterior surface accessible 
for dressings. The same sort of pulley extension is used. This 
splinting prevents dislocation of the head of the radius. 




Fig. 112. — Comminuted fracture of the tibia and fibula. Part of shell in situ. Belgian 
soldier in 2nd Southern General Hospital. (Brit. Jour. Surg., Jan., 1915.) 



Fig. 109 indicates the manner in which the splint is attached. 
Fig. 1 10 is a radiogram of the arm pictured above. This splint is appli- 
cable also to fractures involving the lower end of the humerus alone. 

In the case pictured in Fig. in, the patient, a Scotchman, in a 
Paris hospital, had a fracture of the lower end of the humerus and 
the ulna. Both fractures were reduced and held by this splint. 



11 



l62 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

Fractures of the tibia and fibula present points of special impor- 
tance because of the probability that the blood supply will be com- 
promised and all the soft parts implicated; and in the case of the 
ends of the bones, the joints will be involved (Fig. 112). 




Fig. 113. — Double transfixion apparatus applied to the femur. Note the absence of 
parallelism of the transfixion pins, the manner in which the metal hoop is attached to the 
lower pin, and the manner in which the screw extension bars connect upper pin with hoop - 
below. (Groves, Brit. Jour. Surg., Jan., 1915.) 

The transfixion apparatus is specially recommended for these 
conditions. One pin passes transversely through the head of the 
tibia, the other through the malleoli or os calcis. The same mechan- 
ism as described for the humerus, consisting of a perforated hoop 
with lateral extension bars, is adjusted to these transfixion pins. 

These compound fractures of the upper end of the femur present 
greater difficulties of management than almost any other class of 



TREATMENT OF GUNSHOT FRACTURES 



163 



gunshot injuries. There is always great chance of infection, not to 
speak of the pain which the patient suffers in transportation and 
dressing. 




Fig. 114. — Fractured femur treated by the double transfixion apparatus with little resulting 
deformity. (Groves, Brit. Jour. Surg., Jan., 1915.) 

Immobilization, in many cases, it seems almost impossible to 
secure. The double transfixion apparatus may be applied to these 
cases with prospect of excellent results (Fig. 113). The inner 
transfixing pin is passed through the base of the great trochanter 



164 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 




Fig. lis. — Wooden trough splint for leg fracture. Note angles of inclination of thigh 
and leg. Sides are removable, permitting access to the wounds. (Groves, Brit. Jour. 
Surg., Jan., 1915.) 




Fig. 116. — Cradle splint. Note manner in which weight is attached to the foot-piece- 
By lifting the foot-piece to which the foot is bandaged, the limb may be handled without 
disturbing the traction. (Groves, Brit. Jour. Surg., Jan., 1015.) 



TREATMENT OF GUNSHOT FRACTURES 



165 



antero-posteriorly. The lower pin passes from side to side through 
the condyles. Even in the most severely comminuted shafts good 
union may be obtained (Fig. 114). 

In many of the septic cases it will not be feasible to carry out this 
plan and, again, other forms of treatment must be available where 



■IT 


1 

* 

f ! 
1 

1 


■ wk 


f ■ 


p ^ 





Fig. 117. — The Florschutz method of suspension and extension in the case of fractures 
of the upper end of the femur is more easily adjusted than the Hodgen splint. The uprights, 
which support the horizontal bar, can be attached to any bed and the pulley can be attached 
to any height. In this case, a patient from the 2nd Southern General Hospital, a 12-pound 
bag of sand is used for extension. {Groves, Brit. Jour. Surg., Jan., 1915.) 



there is lack of mechanical skill in the adjustment of such an 
apparatus. 

The wooden trough splint is simple and fairly efficient (Fig. 115). 
It is provided with two inclines, one for the thigh at an angle of 
forty-five degrees and one for the leg. The foot is bandaged to the 
foot-piece and the sides are removable to facilitate the dressings. 

The cradle splint operates on the same principle, except that 



1 66 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

extension is added to position. The foot is bandaged to the foot- 
piece and to this the weight is attached (Fig. 116). It permits 
the limb to be moved without relaxing the pull of the extension 
weight, by lifting the foot-piece off the frame. 

For wounds and fractures near the hip joint the Florschiitz 
method is simple and efficient, the thigh and leg being slung from a 
bar above the bed (Fig. 117). 

TREATMENT OF GUNSHOT WOUNDS OF JOINTS 

In the simple perforating cases the skin is sterilized, the wound 
dressed and the joint immobilized. As soon as the wound is healed, 
begin with cautious passive motion and, usually, an excellent 
functional result is obtained. If, on the other hand, suppuration 
occurs, arthrotomy is indicated. If there is much comminution 
to begin with, the soft parts lacerated, it will often be better to 
amputate. 

The shoulder-joint usually furnishes a good prognosis while, on 
the other hand, the hip-joint presents a bad outlook on account of 
infection and of complications involving the rectum, bladder, etc. 

The knee-joint is very frequently wounded and the damage 
is always serious. Hemorrhage into the joint is a constant feature, 
the hemarthrosis disappearing in about a month in the favorable 
cases. Under conservative and expectant treatment the results are 
surprisingly good. 

TREATMENT OF GUNSHOT WOUNDS OF SKULL AND 

BRAIN 

Most perforating wounds of the skull prove fatal. The fatalities 
increase as the range of the bullet shortens and as the impact ap- 
proaches the base of the skull, death resulting from injury to the 
automatic centers. The most recoveries follow injury to the 
frontal lobes. Blindness may result from injury to the occipital 
lobes. Primary union of the scalp wound is an element in favorable 
prognosis, since by this means infection is more likely to be eliminated. 

First aid on the battlefield will look to the hemorrhage. The first- 
aid dressing should include both the wound of entrance and exit. 
In the case of external hemorrhage, packing the wound is contra- 



TREATMENT OF GUNSHOT WOUNDS 



167 



indicated; a few strips of sterile gauze loosely packed in the wound 
will favor hemostasis and antisepsis. At the field hospital a cra- 
niectomy should be done. 

All surgeons experienced in recent wars agree on the necessity of 
exploring every such wound as soon as possible. Where long trans- 
portation is necessary before a trephining can be done, the mortal- 




FiG. 118. — Bullet in the tentorium cerebelli. Large clear space above indicates part of skull 
blown away. Operation; good recovery. {Harris, Brit. Jour. Surg., Jan., 1915.) 



ity is naturally greatly increased. Enlarging the wound in the 
scalp, enlarging the wound in the skull sufficiently to remove all frag- 
ments of bone and debris, controlling the hemorrhage and providing 
drainage — these represent the chief elements of relief. (See Urgent 
Craniectomy.) If infection occurs the wound is to be opened up. 
Disturbances of the sensorium, of motion and sensation often improve 



1 68 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 




Fig. 119.— Bullet lying in the petrous portion of the temporal bone. Treated by temporal 
decompression; bullet left in situ; good recovery. (Harris, Brit. Jour. Surg., Jan., 1915.) 




Fig. 120.— Bullet lying in tentorium cerebelli, having entered left parietal region. 
Marked cerebral compression. Wound of entrance trephined. Bullet removed later, tre- 
phining the right occipital region. Good recovery. (Harris, Brit. Jour. Surg., Jan., 1915.) 



TREATMENT OF GUNSHOT WOUNDS 1 69 

as by magic following these interventions. A study of the case reports 
from European hospitals confirms these views (Figs. 118, 119, 120). 

TREATMENT OF GUNSHOT WOUNDS OF THE FACE 

The chief dangers in these wounds are hemorrhage, infection and 
interference with respiration. The eye, the fifth and seventh nerves, 




Fig. i2i. — Bullet lodged in the base of the neck, having first perforated the tuberosity 
of the humerus and the acromion process. Note that the bullet is turned end for end and is 
pointing at the wound of entrance. (Harris, Brit. Jour. Surg., Jan., 19 15.) 

are most likely to be involved and these injuries are to be treated on 
general principles. Control of hemorrhage may call for ligation of 
the facial, temporal or even the external carotid arteries. Careful 
cleansing and packing with iodoform gauze secure excellent results. 

TREATMENT OF GUNSHOT WOUNDS OF THE NECK 

These wounds are always dangerous and yet in no other region 
does the unexpected more frequently happen in the passage of a 



170 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

bullet. The fact of hairbreadth escape of important structures is 
explainable only by the small size of the army bullet and the mobility 
of the structures (Fig. 121). The transverse or oblique track is 
most common. Such wounds as are not immediately fatal are 
likely to recover. Sepsis usually has its origin in the air passages 
or the esophagus. Injuries to the trachea give rise to hemoptysis, 
emphysema or broncho-pneumonia. Gangrene of the esophagus 
may occur. Aneurism is not infrequent. Any of the nerves may 
be injured. 



• 








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mm m.miWk 


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Fig. 122. — French boy (Hotel Majestic) shot from side to side through the neck, the bullet 
passing between the trachea and esophagus. Tracheotomy required on account of dyspnea. 
Leakage of fluids from an esophageal fistula which closed in a few days. Tracheotomy tube 
still in place. (Thorburn, Brit. Jour. Surg., Jan., 1015.) 

No special treatment is called for beyond the hemostasis and 
antisepsis, unless occasionally a tracheotomy may be indicated 
(Fig. 122). 



TREATMENT OF GUNSHOT WOUNDS OF THE SPINE 

The treatment of wounds of the spine must be conservative; that 
is to say, that very rarely will immediate operation be indicated. 
Absence of the deep reflexes must not be taken to indicate complete 
rupture of the cord but if motion and sensation do not improve in 



TREATMENT OF GUNSHOT WOUNDS 171 

ten days a laminectomy may be performed. If the laminectomy 
does not seem to restore the pulsation of the cord the theca must be 
opened and the clots removed. Recovery does not always take 
place even though the cord is not lacerated. 

TREATMENT OF GUNSHOT WOUNDS OF THE ABDOMEN 

Rotter (Berlin. Medizin. Clinik, Jan. 13, 1915) states as the 
result of his studies of this class of injuries that the mortality on the 
field is 90 per cent. ; among those living to reach the field hospital 
80 per cent, die; of those reaching the clearing hospitals 40 per cent, 
die, and finally those who reach the base hospitals recover. 

Spontaneous cure is possible only when the perforation is small 
and single and the bowel empty. If the patient is seen within 
twelve hours he advises operation and states that the conditions are 
so good in the German field hospitals that one need not fear sepsis 
by reason of the operation done there. 

From the other armies the reports are not so favorable to operative 
treatment and most of the authorities reluctantly admit the ineffi- 
ciency of operation in the field hospitals and the better, though 
unsatisfactory, results of conservative treatment. The prognosis 
varies with the part of the digestive tube involved. The ascending 
and descending colon and the cecum gives the best prognosis; the 
stomach is not quite so favorable, and the perforation of the trans- 
verse colon and small intestine are most likely to result fatally. 

TREATMENT OF WOUNDS OF THE THORAX 

The non-perforating wounds need only an antiseptic dressing. 
Broken ribs will require adhesive strapping. 

The perforating wounds presenting no special indications of 
hemorrhage from the chest wall are to be treated by aseptic occlusion. 

The internal mammary or the intercostal arteries may need to be 

controlled. If the hemorrhage is visceral, opium and compression 

! of the chest wall by firm bandaging seem to be the last resort in time 

of war. Under no circumstances is the wound to be probed or 

examined with the finger. Transportation is always to be feared. 

1 



172 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 



In every way the patient is to be kept as quiet as possible. He must 
be made to realize the seriousness of his injury. Paracentesis should 
not be performed in the case of hemothorax until the bleeding has 
ceased. Thoracotomy is to be performed if suppuration occurs. 
(See Injuries of Thorax.) 




Fig. 123. — Fragments of Vickers- Maxim i-pound shell. (Makins.) 



SHELL AND SHRAPNEL WOUNDS 



^ 



These wounds constitute a very large percentage of the casualties 
of battle. Following the usual classification they may be designated 
as contusions or lacerations, much more frequently the latter. 

These injuries may be arranged in groups: 

1. Large, destructive, mutilating wounds, often resulting in 
immediate death. A whole limb may be irrevocably damaged; 
half the skull shot away; the thoracic or abdominal cavities torn 
open. 



SHELL AND SHRAPNEL WOUNDS 



173 



2. A multiplicity of small wounds penetrating no deeper than the 
fascia and containing fragments of the shell or its contents. There 
may be thirty or forty such wounds scattered over the trunk and 
limbs. 

3. Surface wounds; the margins irregular; the skin often bruised or 
burned; no fragments retained. 




Fig. 124. — Shrapnel bullets normal and deformed. (Makins.) 



4. Penetrating wounds caused by a single fragment of shell, 
passing right through the affected region. The wound exit is always 
much larger than wound of entrance. Its edges are everted, fat and 
muscle tissue often protruding. The edges of the entry wound are 
inverted and often charred. The tissues are widely destroyed, the 
skin presenting a brawny appearance, due to interstitial hemorrhage. 

5. A single penetrating wound, the fragment retained. As in 
the other cases the amount of deep damage is out of proportion 
to the size of the wound entry. That these projectiles should pro- 



174 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

duce such terrible lacerations in many cases is at once apparent frorr, 
a study of their character (Figs. 123, 124, 125). 

Isolated injuries to nerves and vessels are unknown. Muscles, 
vessels, nerves and bones all share together in the destruction caused 
by these irregularly shaped missiles. The great tendency to infec- 
tion is not inherent in the wound but in the environment, for accord- 
ing to Pannett it is astonishing how mild the infection is in such 




Fig. 125. — Fragments of shells (two-thirds natural size) removed from various wounds 
received in naval combat. The shrapnel fired by the Germans consist of irregular metallic 
fragments — not the round bullets found in English shrapnel pictured above. (Panneti, 
Brit. Jour. Surg., Jan., 1915.) 



wounds received in naval warfare, by reason of the absence of 
earth dust and, in many cases, by reason of a longer or shorter sea 
bath (British Journal of Surgery, Jan. n, 1915). 

In the limbs all degrees of destruction are met with, from absolute 
mangling to tearing of the soft parts with compound comminuted 
fractures of various degrees. Whether immediate amputation shall 
be practised depends on general principles referable to the blood 






SHELL AND SHRAPNEL WOUNDS 



175 



supply. If the circulation of the member is compromised beyond 
hope, amputation should be performed without delay (Fig. 126). 




Fig. 126. — Shrapnel wound. Comminuted fracture of the femur. Frightful mangling of 
soft parts. Amputation. (Harris, Brit. Jour. Surg., Jan., 1915.) 



In other cases, especially if the wound is produced by the leaden 
balls of shrapnel, the limb may be treated as in the ordinary case 
of compound fracture (Fig. 127). 



176 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

Lacerated scalp wotmds with compound fracture of the vertex 
are common. 




Fig. 127. — Fracture of lower third of ferriur. Round shrapnel ball in situ. (Harris, Brit. 

Jour. Surg., Jan., 1915.) 



In the face, horrible disfigurements result; an eye may be de- 
stroyed; the mouth cavity exposed; the bones of the orbit, face or 
jaws splintered. 



SHELL AND SHRAPNEL WOUNDS 1 77 

i 

Chest injuries of this type are usually fatal, either from shock or 
hemorrhage. 

Occasionally, however, a fragment of shell may traverse the 
thorax with a result no more serious than a severe hemothorax. 
Small fragments may be deflected by the ribs without fracture. A 
fragment may lodge in the thorax and empyema is likely to ensue 
(Fig. 128). 




Fig. 128. — Shell wound of base of thorax. Empyema and subphrenic abscess, com- 
municating through a hole in diaphragm. (Thorburn, Brit. Jour. Surg., Jan., 19 15.) 



In the abdomen such wounds are almost universally fatal. If 
the wound is limited to the parietes, however, recovery may follow. 
In some such cases the contusion of the bowel may result in a fecal 
fistula (Fig. 129). 

All these wounds are to be treated along the lines already dis- 
cussed in connection with bullet wounds. In the matter of amputa- 
tion Fitz Maurice Kelly calls attention to the great advantages of a 
12 



178 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

simple circular section of all tissues at the same level. After infec- 
tion is passed a second operation is done and flaps formed. 




' 



Fig. 129. — Shell wound perforating abdomen. Arrow shows aperture of entry; the top- 
most wound the exit; the middle wound marks site of a subsequent fecal fistula leading into 
the descending colon. (Pannett, Brit. Jour. Surg., Jan., 1915-) 



BOLO WOUNDS 

According to Foxworthy (Ft. Wayne Medical Journal, June, 1902), 
every insurgent in the Philippines was armed with a bolo. "This 
bolo was of iron with a wood or bone handle and varied in shape and 
size from a sword to a dagger and from a corn knife to a meat ax. 



BOLO WOUNDS 1 79 

It was generally a cruder weapon than the Cuban machete, but 
very effective in close encounters. As it could be concealed 
beneath the loose jacket, it was more serviceable than a sword or 
saber, which was always visible. The kries is a weapon similar to 
the bolo, but with a wavy edge like a Christy bread-knife. It is 
often two-edged. The wounds produced by the bolo and kries were 
often of great length and usually infected. 

" Another class of wounds was caused by spears and tomahawks, 
used by the Igorrotes and Negrites. The tomahawk, having a 
concave edge, was not so apt to glance off the skull as an Indian 
tomahawk. A blow split the skull wide open. 

The spears were often of bamboo, sharpened to a fine point, and 
their penetrating power was almost equal to that of an iron-tipped 
spear. The iron-tipped spear had from one to four barbs which 
made an exceedingly ugly penetrating wound and usually had to be 
cut out. These wounds were always infected and tetanus fre- 
quently developed." 

FIRST AID ON THE BATTLEFIELD 

Colonel Nicholas Senn, in his address before the Lisbon Inter- 
national Medical Congress, 1906, formulated the principles of first 
aid on the battle field, and his conclusions though needing revision 
in the light of recent events are nevertheless herewith summarized: 

(1) The fate of the wounded depends largely upon the time 
and thoroughness with which first aid is rendered. This first aid 
for many reasons cannot be rendered by the surgeon, but must be 
given by comrades or by the wounded man to himself. First aid 
administered in this manner will be effective, owing to the aseptic 
character of the chief wounds of battle, if previous instructions 
have been given. It is absolutely essential that the soldier should 
receive this elementary instruction when he is taught the art of war, 
and it should not be postponed as has beei^ done only too often in 
the past until war clouds make their appearance. 

(2) The first-aid dressing should combine simplicity with safety 
against post-injury infection. It should be on the person of every 
combatant and must be simple to be efficient. It must be compact 
and easy of application. 



l8o GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 



"The dressing consists essentially of two pads of cotton, wrapped 
in gauze, and fastened together by two stitches and continuous 
with a gauze roller, which is made use of instead of the triangular 
bandage for holding the dressing in place and for immobilizing the 
injured part. The gauze roller should take the 
place of the triangular bandage in every first-aid 
dressing as it requires much less space and is more 
serviceable as a means of fixation and support. 

"The brown iodine spot in the center of the pad 
on the side to be brought in contact with the 
wound corresponds with the location of the anti- 
septic powder incorporated in the absorbent cotton 
and serves as an infallible guide in applying the 
pad in the right place." 

(3) The first aid must have in view the treat- 
ment of shock and hemorrhage, dressing of the 
wound, and immobilization of the injured part. 

The treatment of shock in the field is very un- 
satisfactory, but, fortunately, shock is not a char- 
acteristic of small-caliber bullet wounds. Rest in 
the recumbent position; hypodermic injection of ^ 
grain of morphine; spirits internally — these answer 
the most urgent indications. 

The treatment of hemorrhage at the front must 
be conducted with the greatest caution. Elastic 
constriction, if too generally practised, will do 
vastly more harm than good. It should be applied 
only in exceptional cases and then by a competent 
member of the hospital corps or a medical officer, who must make 
it his duty to send the case to the first dressing station as 
quickly as possible, where definitive hemostasis can take the place 
of the constrictor. There are less harmful means of hemostasis 
which will be efficient in most cases: elevation of the limb (Figs. 
130, 131), acute flexion of the joint above the wound (Figs. 132, 
133), digital compression over the dressing — these are measures 
which must be taught. 

Direct treatment of internal hemorrhage of any of the large 




Fig. 130. — Eleva- 
tion of upper ex- 
tremity in the treat- 
ment of hemorrhage. 
(Senn.) 



FIRST AID ON THE BATTLEFIELD 



181 



cavities is entirely out of the question at or near the firing line. The 
cartridge belt, suspenders, or gunstrap can be used to the greatest 
advantage in limiting respiratory and abdominal movements and 
thus secure for the vascular bleeding organs a condition of rest, 
conducive to spontaneous arrest of hemorrhage (Fig. 134). 




Fig. 131. — Gunstack for elevation of the lower extremity. (Senn.) 



Immobilization is an essential part of first-aid treatment, con- 
ducing to primary repair, relieving pain, and preventing infection 
by securing the first-aid dressing. 

The ideal fixation splint in such cases would be the plaster-of- 
Paris splint, but this method of fixation is entirely out of the question 
on the firing line and must be reserved for the dressing station of 
field hospital. This first-aid fixation must be extemporized. 
The sound leg may serve as a splint for the wounded one which is 
held in place by belt, gunstrap, handkerchief, etc. The rifle, 
bayonet, and saber are always available as splints (Figs. 135, 

136, 137)- 

A fractured humerus may be splinted to the side of the body. 



1 82 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 






A well-padded bayonet will meet the indications in fracture of the 
forearm. The wire netting cut in the shape corresponding to the 
fixation of the different fractures of the limbs should be carried to 
the front by the sanitary corps in sufficient quantities to meet the 
expected requirement. Splints made of this material, well-padded, 
will answer an excellent purpose as first-aid fixation, as they can be 







Fig. 132. — Forced flexion of the elbow-joint in arresting hemorrhage from the brachial in 

that region. (Senn.) 



molded into shape and can be used subsequently to strengthen the 
plaster bandage at the dressing station. 

(4) The first-dressing station is the most important place for 
skilled aid. This primary depot of the wounded should be estab- 
lished in a sheltered place as near as possible to the firing line, 
protected as much as possible against the fire of the enemy. 

(5) Probing of recent gunshot wounds must be prohibited by the 



FIRST AID ON THE BATTLEFIELD 



183 



most stringent rules. Under no circumstances should attempts be 
made to remove bullets until this can be done under strict aseptic 




Fig. 133. — Forced flexion of the knee in hemorrhage from the popliteal region. (Senn.) 

precautions in the hospital, and then only in those cases in which 
such operation is clearly indicated and the exact location of the 
bullet has been determined by palpation 
through the intact skin or by the use of the 
"X-ray." 

(6) The surgeon's most important duties 
at the first-dressing station are: 

(a) Inspection of first-aid dressing. If it 
is in its proper place, label to this effect that 
it may not be unnecessarily removed at the 
hospital. If defective, it must be renewed 
or more securely fastened. 

(b) Application of plaster splints to the 
fractured limbs; the wire-netting splints are 
cut into strips and incorporated in the plaster- 
of-Paris dressing. 

(c) Emergency operations. The operative 
treatment of gunshot wounds must be limited 
to the most urgent cases. The definitive 
arrest of hemorrhage — of dangerous external 
or internal hemorrhage — stands pre-eminent 

. Fig. 1 3 4 -—Perforating 

in the list of emergency operations. Iodized wound of chest, aseptic tam- 
catgut is the proper ligature material for field p° nnade and immobiiiza- 

tion by circular compression. 
Service. ■ (Senn.) 




1 84 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 

Intra-cranial and intra-thoracic hemorrhage should not be inter- 
fered with outside of a well-equipped hospital. Dangerous intra- 
abdominal hemorrhage calls for prompt operative interference. 




Fig. 135. — Saber splint for leg and thigh. (Senn.) 

Abdominal section under such circumstances, in a tent, may con- 
tribute much in lessening the mortality from hemorrhage by a 
resort to ligature, suture, or aseptic tamponade. 




Fig. 136. — Gun splint. (Senn.) 

By pursuing this aggressive course, some lives may be saved by 
prompt interference which would be lost by the let-alone treatment. 




Fig. 137. — Stick and blanket splint. (Senn.) 

Wounds of the larynx and trachea which have given rise to respira- 
tory difficulties, either from emphysema or hemorrhage, call for an 
immediate tracheotomy. 



FIRST AID ON THE BATTLEFIELD 1 85 



of the joints, is obsolete. 

Amputation must be reserved for cases in which a limb has become 
mangled by a cannon ball or fragment of shell or in which the 
fracture is complicated by division of the principal blood-vessels and 
nerves. 

Laparotomy in the field, for gunshot wounds of the abdomen, 
with a view of finding and suturing perforations of the gastro- 
intestinal canal, has not yielded in practice the anticipated results, 
and hence must be restricted to exceptional cases. 

Clinical experience has shown that in a fair percentage of cases 
penetrating wounds at and above the level of the umbilicus, inflicted 
in the antero-posterior direction, do not implicate the gastro- 
intestinal canal, and in such cases conservative treatment yields 
better results than operative. On the other hand, in wounds involv- 
ing the small intestine area, more especially when the bullet takes 
an oblique or transverse course, we may confidently expect to find 
from three to fifteen perforations, and it is in this class of cases in 
which immediate laparotomy offers the only chance of saving life. 

(7) The surgeon's field case should be light, compact, and the 
instruments wrapped in a canvas roll, so that instruments and 
envelope can be quickly sterilized in boiling soda solution. 



CHAPTER XIII 
GUNSHOT WOUNDS IN CIVIL PRACTICE 

The projectiles of the ordinary fire-arms of civil life differ from 
those used in warfare, in that they are composed of soft lead, are 
easily deformed, are of slight initial velocity, and are usually fired 
at short range. 

The revolver and pistol, flobert and shot-gun produce the wounds 
most frequently seen. 

Of the shot-gun it may be said that the wounds which it produces 
are very likely to be either greatly destructive or comparatively 
harmless. At close range the charge, acting as a single body, lacer- 
ates and shreds the tissues; at long range a number of small per- 
forations are made. 

The dangerous wounds, then, have all the characteristics of lacera- 
tions and demand the treatment of lacerated wounds in general. 
It must always be assumed that foreign bodies have been carried 
into the tissues and that these wounds are therefore infected. 

It is the bullet wound of the revolver, however, which it is most 
practical to consider. To a limited extent, its pathology is similar 
to that of the army bullet, and it is unnecessary to state again the 
effect of a bullet upon the various tissues. It is expedient to con- 
sider at once, with especial reference to treatment, the bullet 
wounds of certain localities. 

But let it be emphasized in this connection that the course of the 
bullet can never be accurately determined. 

Always be on the alert for the unexpected and insist, however 
simple the wound may appear to be, that the patient be kept under 
close surveillance. The wound may seem to be a flesh wound of the 
thigh, for example, and may be dismissed as such; later, and too late 
perhaps, it may be discovered that the peritoneal cavity was involved. 
And this happened to a boy of ten who was brought to the City 

1 86 



BULLET WOUNDS OF THE HEAD 1 87 

Hospital with not the slightest symptoms to indicate any serious 
injury. Too late, it was found that the intestine was perforated 
in many places. 

Again, however well assured we may be that no serious damage 
has been done we shall nevertheless w r atch for signs of hemorrhage 
or beginning infection. 

We must remember, too, that infection may develop late. 
A man of thirty-five was brought in with a 38 bullet wound in the 
region of the knee. His limb was swelling rapidly and he was im- 
mediately prepared for operation. 

The bullet had bored through the upper end of the tibia from in 
front backward and lodged in the popliteal space. A counter open- 
. ing was made from behind, the bullet extracted. The hemorrhage 
indicated an arterial wound and following the track of the bullet, 
. the anterior tibial was found divided near its point of origin. It was 
. ligated, the posterior opening in the tibia located and a strip of gauze 
I saturated with iodine passed through the hole in the bone. Drain- 
age left in both anterior and posterior openings. 

For a week the patient did well and was thought to be entirely 
out of danger. At that time however his temperature rose and very 
shortly there were signs of suppuration and, in spite of free drainage, 
gangrene developed and the limb was amputated well above the 
knee. But the flaps refused to heal and, grave symptoms of general, 
, sepsis supervened. He died three weeks after his injury and the 
postmortem revealed a septic thrombus along the whole length of 
the femoral vein. 

WOUNDS OF THE HEAD 

The region of the brain is usually w T ounded in attempts at suicide, 
, and it is the right temple or forehead which is most frequently se- 
. lected. The vertex, postero-lateral, and occipital regions are seldom 
wounded and only then as a result of accident or assault. 

As medico-legal questions are often involved in these cases, it is a 

] wise practice to make careful and systematic examinations. Learn 

as much as possible about the character of the fire-arm, the nature 

I of the projectile, the position of the patient at the time of injury, 

/ 



1 88 GUNSHOT WOUNDS IN CIVIL PRACTICE 

Examine the ears and nose for blood, inspect the mouth, examine the 
head for a wound of exit, or see if the bullet can be located beneath 
the scalp. 

Next examine the wound itself, but not until the field and wound 
have been sterilized. Begin the disinfection by shaving the scalp 
about the wound. Wash with soap and water and then with alcohol 
or bichloride. 

Enlarge the wound by a cross incision, if necessary, and wipe out 
with sterile gauze, removing all forms of foreign bodies. 

Finally examine the skull. If you find a mere depression without 
penetration, it is sufficient to pack the opening with sterile gauze, 
and bandage. Later the bullet may be located with the " X-ray" 
and removed, if it becomes troublesome. If the bullet is visible and 
removable without much difficulty, it is better to take it out 
at once. 

If the ball has penetrated the entire thickness of the skull and 
lodged within the cavity, the size of the orifice will be some index as 
to its probable depth; if the orifice is large, it argues for close range 
and deep lodgment. If the opening is small, comparatively speak- 
ing, it is likely that the ball has not penetrated deeply. Note the 
direction of the fissures. If the base is involved the prognosis is 
always serious. Note the condition of the dura: it may be lacerated 
and the brain tissues may exude. If such is the case, the bullet is 
obviously in the brain, but its exact location must remain a matter 
of doubt. It is not expedient to explore it; it is not even advisable 
to attempt to disinfect the cerebral wound. 

It is sufficient to remove all fragments of bone and debris and 
wipe the wound dry with sterile gauze. On these two points, how- 
ever, there may be some difference of opinion. The American Text- 
book of Surgery insists upon the value of disinfection of the entire 
cerebral track of the bullet and of through-and-through drainage 
under certain circumstances; also upon the advisability of attempting 
to locate the bullet by the aluminium gravity probe, and to remove it. 
Still it may be said that the general practitioner has done his duty 
and done it well if he has cleansed the skull and dural wounds and 
controlled the hemorrhage. (For further details of treatments, see 
Urgent Craniectomy.) 



TREPHINING THE SPINAL CANAL 



189 



ie GUNSHOT WOUNDS OF THE SPINE 

A man was brought into the City Hospital shot in the back with 
. a 38 revolver. Except that he was paralyzed from his hips down 
and without control of his bladder and bowels, his condition was 
good. This positive primary paralysis pointed to grave injury to 
the cord. At the operation it was found that the bullet had smashed 
into the spinal canal and there lodged, completely obliterating in 




Fig. 138. — Complete division of spinal cord; bullet retained. 



its course a considerable segment of the spinal cord (Fig. 138). 
Suture of the cord was out of the question, so the poor fellow — a man 
of great vitality — was condemned to linger in living death for many 
weeks. 

Happily not all cases of gunshot wound involving the cord are 
beyond relief. Whenever the symptoms point to severe injury of the 
cord — whenever there are notable disturbances of sensation and 
motion — -and improvement fails to take place shortly, it is bad 
practice to delay. It is indicated to cut down upon the spine, re- 
move a spinous process, trephine into the canal, and cautiously cut 
away the arches. It may develop that the symptoms are due 



190 GUNSHOT WOUNDS IN CIVIL PRACTICE. 

merely to pressure of fragments of bone which are to be removed. 
If after gunshot wounds of the spine there are no cord symptoms 
or if they are mild and tend to improve, it is better not to operate. 
The smaller the projectile the less the likelihood that operation will 
be required. Without some positive indication in the cord, there- 
fore, aseptic occlusion is the treatment to pursue. Probing is all the 
more perilous because infection may be carried directly to the spinal 
meninges. 

GUNSHOT WOUNDS OF THE FACE 



These may result from shots into the mouth with suicidal intent. 
Small bullets may remain imbedded in the hard palate or posterior 
pharyngeal wall. The instinctive tilting of the head backward 
gives the bullet a characteristic course through the hard palate or 
the root of the nose, and, owing to the involvement of the base of 
the brain, such wounds are deadly, except with quite small fire- 
arms. 

In other cases there are grave comminuted fractures of either jaw. 
Sometimes there are powder burns and disintegrations suggestive 
of explosions. 

The chief dangers in cases not immediately fatal are from inter- 
ference with respiration and from hemorrhage. These wounds are 
also predisposed to infection, and as a result of sepsis secondary 
hemorrhage is not infrequent. Paralysis of the facial nerve may 
occur. The salivary glands or their ducts may be injured and give 
rise to a troublesome dribbling of saliva. Marked interference with 
respiration may call for immediate tracheotomy. 

Arteries may need to be ligated and ligation may be difficult owing 
to their relation to the bones. The oozing, always marked, is to be 
controlled by pressure. The natural contour is to be restored a 
much as possible after a thorough cleansing, and the wound cavitie 
packed with iodoform gauze. A young man was brought to the City 
Hospital with gunshot wound of the face, the range so close the skin 
was powder burned. He was bleeding profusely from the mouth. 
It was found that the bullet, a 38, had entered the left upper- jaw, 
passed through it into the nasopharynx, carrying away part of the 
soft palate and still ranging slightly downward had lodged in the 



: 



TREATMENT OF GUNSHOT OF CHEST 191 

. middle of the neck of the opposite side. It was located about the 

1 depth of the sterno mastoid. An incision under local anesthesia was 
made and a dissection carried down to the bullet. It was grasped 
with forceps but slipped away and on further attempts to seize it, 
was pushed back into the pharynx and coughed out. 

The wound in the jaw was injected with peroxide which escaped 
through the mouth. 

Finally a slip of sterile gauze w r as carried through the channel in 
the jaw, one end of the strip left in contact with the lacerated tissues 
of the soft palate, the outer end projecting from the wound. Some 
oozing persisted for twenty-four hours. On the second day the strip 

I was removed and the wound injected with weak peroxide solution. 

I No infection arose and he recovered rapidly, apparently none the 
worse for the injury. 



GUNSHOT WOUNDS OF THE THORAX 

t 

Gunshot wounds of the thorax do not differ from other wounds in 

this region except in their graver prognosis. (See page no, Wounds 

I of Thorax, and page 149, Military Practice.) Such as involve the 

: great vessels at the root of the lungs and most of those which involve 

the heart are not even of interest from a standpoint of treatment 

because so rapidly fatal as to preclude intervention. 

Such wounds as are not obviously fatal, whether they involve the 

pleura and lungs or the pericardium and heart, present three sources 

: of danger: hemorrhage, asphyxia, and infection. These are the 

three conditions which determine the line of treatment, and which 

I have already been discussed under the head of Wounds of the 

I Thorax. 

Aside from these symptoms of urgency, the treatment must be 
conservative and expectant — -quite different from gunshot wounds 
of the abdomen. 

Begin by covering the wound with an aseptic compress and then 
carefully disinfect the field. Finally cleanse the wound itself and 
dress antiseptically. Avoid probing or other explorations. 

Transportation must also be avoided, for there can be no doubt 
that it is often disastrous. In the country, where ambulances are 
out of the question, the nearest shelter is the best. 



192 GUNSHOT WOUNDS IN CIVIL PRACTICE 

If it is evident, finally, that the hemorrhage is increasing, as indi- 
cated by the symptoms and physical signs, conservatism is no longer 
rational and the wounded lung should be exposed and the tear 
repaired. In the event a tear is found in a pulmonary vein a | 
ligature must be placed on either side of the tear. Recovery may 
follow without lung complications. 

Kutner, of Leipsic, proposes in the future when dealing with these 
wounds to evacuate the extravasated blood if it is not promptly ab- 
sorbed, suturing the pleura without drainage. In the case of an 
already collapsed lung it does not appear that there would be in- 
creased danger operating without the aid of a Sauerbruch cabinet. 

BULLET WOUNDS OF THE ABDOMEN 

With reference to prognosis and treatment, these wounds fall into 
three clinical groups: those which are obviously penetrating and ac- 
companied by grave visceral lesions; those which are doubtful both 
as to penetration and visceral injury; and those which are probably 
benign. 

(A) One concludes that a certain wound is grave not from ob- 
serving the escape of gas and fecal matter, or hemorrhage from the 
wound, for these are too infrequent to be relied upon, but from the 
general condition, which alone is of sufficient significance. The 
pulse is small and rapid; the face is drawn and pale; the belly wall 
is distended and resistant to the least pressure; dullness of the ilia 
fossa and flanks develops and there may be vomiting of stomac 
contents or of blood. 

The persistence of these symptoms for the first two or three hour 
is sufficient to dispel any illusion of the more sanguine that the cas 
is not dangerous. 

There is but one thing to do, operate as soon as possible. 

This is a principle so definitely established that the citation of a 
long list of eminent authorities is unnecessary: a rational doctrine 
that all may accept. 

There are contingencies of time and place, of septic environment 
which would insure that the operation itself would likely be fatal, 
but those conditions are very exceptional in civil practice with the 



TREATMENT OF GUNSHOT OF ABDOMEN 1 93 

doctor who has the "savoir-faire." An exceptional condition does 
not alter the principle, and he who does not act at once, must incur 
the reproach of having refused the wounded the best resource of 
safety. 

There is another consideration. One may not be called to see the 
case until after two or three days have elapsed and may then en- 
counter one of two eventualities: one almost certain, the other 
unlikelv. 

In the first, there are the signs of general peritonitis. Under these 
circumstances, again, the rule is to operate, though on]y as a forlorn 
hope. 

On the other hand, it may be that despite the apparent gravity 
of the wounds, the pulse is good, there is no vomiting, the abdomen 
is not tender, there has been a passage of flatus or a movement of 
the bowels. Although we know these appearances are often deceitful, 
that it may be only the lull which precedes the storm, yet we are 
perfectly justified, under these circumstances, in maintaining an 
" armed expectancy." Under such circumstances, control peris- 
talsis with a little morphia, impose an absolute quiet and absence 
of food, and in the meantime have the patient under vigilant 
surveillance. 

Fysche reports a case of abdominal gunshot wound, which shows 
the value of drainage and which might be taken as an indication of 
the course to pursue in certain desperate cases, where, for example, 
the circumstances of time or place, the condition of the patient, or 
the isolation and lack of skill of the operator precluded a more 
rational and definite procedure. 

A boy of fourteen was shot through the abdomen at close range 
with a large-caliber revolver. The bullet entered just to the in- 
side of the right anterior-superior spine. There were all the signs 
of shock and internal hemorrhage. The abdomen was opened 
with immediate escape of blood and fecal matter. The first por- 
tion of the small intestine examined revealed a perforating wound. 
This and two other wounds were repaired, but the boy's condition 
called for haste and a hurried examination developed seven more 
perforations of gut and mesentery along the 6 feet exposed. The 
abdominal incision was closed with through-and-through sutures 
13 



194 GUNSHOT WOUNDS IN CIVIL PRACTICE 

with a large deeply placed drainage wick in the lower angle. He 
was freely stimulated and given large enemas of normal salt solution. 
The drainage was removed on the second day and from the opening 
there was a free fecal discharge. On the third day his bowels 
moved naturally. Thereafter the fistula closed rapidly and in a 
month he seemed quite well. (Montreal Med. Jour., May, 1909). 

(B) The case is one of doubtful penetration and therefore doubt- 
ful visceral injury. 

You are called immediately. You find nothing more than a 
bullet wound in some part of the anterior abdominal wall. The 
pulse is good, the abdomen is neither rigid nor tender, and there is 
no other indication worth noting. 

Now, what are you to do? Wait several hours watching for some 
indication? But this is a dangerous formula, subject to various 
interpretations, for, as Lejars asks, what shall be regarded as the 
first " indication" — the weaker pulse, the tympanites, the altered 
facies? But these are the signs of beginning peritonitis. 

It is better, as Brown, of St. Louis, and many others have so defi- 
nitely determined, to answer the question resolutely in these terms: 
prepare at once to operate; determine whether the wound is a pene- 
trating one or not, and if so, proceed with the laparotomy — pro- 
vided, of course, that the situation is such that it can be done with- 
out very grave danger from the operation itself. It may develop 
that the operation is not necessary, but it will very much more fre- 
quently become evident that it is indispensable. 

Admit that these urgent laparotomies are difficult, that they strain 
every resource of emergency antisepsis and surgical skill, that the 
perforations are often multiple, that one never knows just what he 
must meet. Admit that some recover from these wounds without 
operation, but are we authorized by that to expect in another case 
so fortunate a denouement? Admit that the patient has several 
chances of recovery without operation perhaps, but let us remem- 
ber we have no means of calculating such chances even in the more 
favorable cases, and certainly the chance of an exceptional proc- 
ess cannot give more hope than an early, regulated, and aseptic 
intervention. 



TREATMENT OF GUNSHOT OF ABDOMEN 1 95 

It is prudence which commands operation. As Lejars says, this 
seems the wisest course: 

Prepare for a laparotomy. Begin by cleansing the field of opera- 
tion and then the wound, which is enlarged, cutting from above 
downward, layer by layer. If the peritoneum is found uninjured, 
repair the incision carefully, first trimming the devitalized tissues 
away; under these circumstances, one may safely prognosticate a 
recovery. 

If you find the peritoneum perforated, slightly enlarge that wound 
also, that you may get some idea as to the conditions: a flow of 
blood, bile, intestinal contents, or urine may indicate what one may 
expect. But the fact alone of perforation of the peritoneum is an 
indication to open the abdomen in the middle line — -to do a median 
laparotomy. 

The median incision will be above or below the umbilicus, de- 
pending upon the level of the bullet wound (see Laparotomy for 
Traumatism). 

(C) There are, finally, as Lejars points out, certain bullet wounds 
which, even though penetrating, may be regarded as unlikely to 
have produced serious results. These are such as are produced by 
pistols in which the bullet is quite small and impelled by an insig- 
nificant charge of powder, so that its force is practically spent in 
traversing the abdominal wall. 

And even though the digestive tube should be wounded, the 
opening is not large enough for the contents to escape, for the mucous 
membrane acts as a plug and repair quickly takes place. 

In such a case, there being no doubt as to the facts, it is perhaps 
wiser not to operate, but to treat by aseptic occlusion. Neverthe- 
less it is the part of prudence, however sanguine of the outcome, to 
keep the case under close watch for some days. 

GUNSHOT WOUNDS OF THE JOINTS 

The knee, which is the joint most frequently wounded, may serve 
as a type. Suppose it is wounded by the discharge of a fowling- 
piece, a not uncommon accident. The character of these wounds 



196 GUNSHOT WOUNDS IN CIVIL PRACTICE 

is variable. It may be that only a few shots at long range have 
penetrated the joint, or it may happen that the whole load has torn 
its way into the joint structure. But whatever the condition, no 
active intervention is called for if the case is seen at once. 

Cover the wound with sterile gauze, provide a temporary splint, 
and supervise the transportation. Once under shelter, proceed to 
carry out a methodical cleansing and examination. Cleanse the 
field first and then the wound itself. 

If the wound was received at long range and probably only a 
few shots have penetrated the joint cavity, the careful cleansing, 
antiseptic dressing, and subsequent immobilization will be all that 
is required to bring about an uninterrupted recovery without loss of 
function. 

If the wound was received at close range and the joint is freely 
penetrated by the shot, which have carried in shreds of clothing and 
other foreign particles, the treatment is quite different. 

Suppose the joint is swollen, dark blood oozes out, and the cavity 
is exposed through lacerated wounds: in such a case conservatism 
will not cure. Prepare to operate immediately. Open the joint 
and with hot normal salt solution freely flush out the shot, frag- 
ments of bone and cartilage, blood clots and other debris. Do not 
be sparing of time and patience. Trim away the lacerated tissues. 
If satisfied with the cleansing, suture the deeper layers over the joint 
so as to close it completely, and drain only the superficial wound; 
otherwise, drain the joint cavity as well. Apply an antiseptic 
dressing and immobilize, and expect a good result. 

The situation is again different if the case has been treated first by 
the uninstructed. The wound is seen some time after injury and 
found covered with dirty cloths, or a handkerchief, the worse for 
usage, is stuffed into the wound. No covering at all is always better 
than anything less clean than a sterile dressing. 

The treatment is the same as before — in every way as rigorous 
and systematic — -but there are not the same certainties by any 
means that it will head off sepsis. You cleanse, drain, immobilize, 
and watch. You watch for beginning infection, which for that 
matter may develop in the simpler cases if the cleansing is not 
complete. Fever, pain, swelling of the joint, all rapidly increasing^ 






TREATMENT OF GUNSHOT OF HAND 1 97 

are the signs of beginning infection and suppuration and call for 
immediate action. It is indicated to open the joint and drain. 
(See page 440, Arthrotomy.) 

Bullet wounds produce similar lesions, although usually they are 
of the milder type. Hemarthrosis indicates injury to bone as well 
as soft parts. Sometimes these wounds occur wdth scarcely any 
injury to the joint structure, the bullet lodging in the epiphysis. 
In the milder cases, wdierever the bullet may be, it is better merely to 
cleanse and immobilize, and at a later date, if necessary, the ball 
may be removed. If, how r ever, the hemarthrosis is voluminous, 
it is better to open the joint at once and clean out the cavity and, 
by a happy chance, the bullet may be found and extracted. (See 
also gunshot wounds of joints in military practice, and compound 
dislocations.) 

GUNSHOT WOUND OF HAND 

A pawnbroker, examining a revolver brought in for a loan and 
which was supposed not to be loaded, w r as shot through the hand. 
The 32 bullet passed between the heads of the third and fourth 
metacarpals, splintering the fourth in some degree. The tissues 
were powder-stained along the track of the bullet and the wound 
bled very freely. 

The wound of entrance in the palm was jagged; the wound of exit 
smooth. The w r ounds w r ere cleansed and a slender forceps passed 
through the hand, a piece of gauze attached and pulled into place 
for through-and-through drainage by withdrawing the forceps. The 
bleeding stopped, but later began again, soaking the bandages. 
Syringing the w r ound with peroxide and packing with gauze served 
to check the bleeding for a few hours. This intermittent hemor- 
rhage persisted for two days. 

The hand was soaked twice daily for a half-hour in hot normal salt 
solution; the swelling and pain rapidly subsided and after three or 
four days the wound began to heal without the least evidence of in- 
fection. The ring finger w T as stiff and painful for some time, but 
under massage and passive motion gradually regained its use. 

Injury to the tendons constitutes one of the chief complications 
of gunshot wounds of the hand. Free trimming away of the 



198 GUNSHOT WOUNDS IN CIVIL PRACTICE 

shattered tissues, free drainage and free use of hot normal salt solu- 
tion seem best calculated to promote repair in this class of wounds. 

SUPERFICIAL WOUNDS FROM FOWLING-PIECE 

A farm hand, charged with trespass, was brought to the county- 
jail sorely wounded. Two charges of bird- shot had caught him on 
the fly and peppered his back, buttocks, and the posterior surfaces 
of thigh and calves. Evading his pursuers, aided by the darkness, 
he had reached his cabin exhausted and, without changing his bloody 
clothes, lay thus unattended for two days, when he was discovered 
and arrested. By this time infection had set in. His buttocks 
and calves, particularly, where the shot were thickest, were 
swollen and inflamed. Many of the shot had carried shreds of 
clothing into the tissue: each was a focus of suppuration; none had 
penetrated beyond the skin. The whole injured area was cleansed, 
first with soap and water, and then rubbed vigorously with peroxide 
of hydrogen; the more superficial of the shot were picked out, and 
finally the inflamed surfaces were smeared with Reclus' ointment and 
covered with sheets of gauze held in place by adhesive strips. The 
relief from pain was great. In three or four daily seances the shot 
were all picked out and the inflammation practically gone. 

WOUNDS FROM TOY PISTOLS AND BLANK CARTRIDGES 

Two things are noteworthy in connection with these wounds: 
first, the surprising power of penetration of cartridges supposed to 
be harmless; and, second, the great danger of a tetanus infection. 
The "wad" may be buried out of sight in the tissues, it may entirely 
perforate the hand, or it may produce a superficial laceration. 
As a rule, the hemorrhage is insignificant, which may in a measure 
account for the development of infection, since bleeding is nature's 
means of disinfection. 

These wounds often present the appearance of punctured wounds, 
which, more than others, are likely to furnish conditions favorable to 
the growth of the tetanus bacillus. 

It may be that the disposition of the wad is such that the wound is 
in a manner stopped up, so that oxygen cannot reach the recesses 



PREVENTION OF TETANUS 1 99 

where the bacillus finds its lodgment. It is true that tetanus de- 
velops in only a small percentage of cases, but one can never foretell 
positively what such a wound may do. 

It is the duty of every doctor to warn his clientele of the danger of 
these " Fourth of July" injuries. 

Every case is to be treated as if lock-jaw is not merely a remote 
possibility, but a probability. Free cleansing and douching with 
peroxide of hydrogen is indicated. 

Luckett says (American Journal of Surgery, July, 1906): "These 
wounds should be freely incised, particularly if not seen on the first 
day of the injury, and thoroughly curetted with a small sharp spoon 
until all the small pieces of wad, the unburned grains of powder, and 
all the dirt have been removed. If the wad has entered a metacarpal 
space a counter-incision must be made for through-and-through 
drainage. Having cleaned the wound as thoroughly as can be done 
mechanically, we now resort to chemicals and irrigate with some 
mild antiseptic. After next drying the wound thoroughly, the entire 
cavity should be sw^abbed out with one of the following, named in 
order of choice: 

1. Pure carbolic acid followed by alcohol. 

2. Twenty per cent, tincture of iodine (made by dissolving iodine 
crystals, 20 parts, in ether and alcohol, each 50 parts). 

"3. Plain tincture iodine. 

"The wound should now be packed with moist iodoform gauze. 
A wet dressing is then applied, to be changed daily. Permission 
should be obtained for a prophylactic injection of antitetanic serum. 
Ten c.c. are intra-muscularly injected in the buttocks or thigh, under 
thorough antiseptic precautions." 

Antitetanic powder may be applied to the wound, as advised by 
Calmette. Experiments conducted by Joseph McFarland, of Phila- 
delphia, corroborate Calmette's statements as to the prophylactic 
value of this substance. By its use McFarland was able to protect 
from infection animals which he had inoculated with the tetanus 
bacillus. 



a 



n 



CHAPTER XIV 
FRACTURES OF THE EXTREMITIES 

Definitions. — A fracture is a solution of the continuity of bone 
due to traumatism. 

A simple fracture has a single line of solution and there is no 
lesion of the soft parts. 

A multiple fracture has more than one line of solution of con- 
tinuity in the same bone or several bones. 

A comminuted fracture has so many lines of solution running into 
each other that the bone is in fragments or splinters. 

A complete fracture involves the whole thickness of the bone. It 
may be transverse, longitudinal, oblique, dentate or comminuted. 

In an incomplete fracture, the line of solution does not involve the 
whole thickness or extent of the bone. It may be a fissure, "a green 
stick," a depression or a separation of an apophysis. 

A subcutaneous fracture has no communication with the surface. 

An open or compound fracture has a communication with the sur- 
face, has an accompanying solution of continuity of the skin and the 
subjacent soft parts. 

A spontaneous fracture is produced by an insignificant traumatism 
and is usually pathological, due to disease of the bone. 

An ununited fracture is one in which bony union has not occurred 
at the usual time. 

Gunshot fractures are those produced by projectiles (see Gunshot 
Wounds). 

Fractures of the extremities are emergencies, often of the first- 
class; their reduction sometimes becomes equivalent to a major 
operation. But it cannot be said that these cases are always treated 
well. As Senn says, "Bad results following fractures have been the 
tombstones that have marked the termination of an otherwise suc- 
cessful prof essional career of many an ill-fated, unlucky, disappointed 
practitioner. " 

200 



DIAGNOSIS OF FRACTURE 201 

Malpractice suits more frequently follow this class of cases, per- 
haps, than any other, which is an indication that somewhere there is 
a fault. Doubtless it is the fear of a damage suit that often makes 
a basis for it and in this way: The doctor, in order that he may have 
testimony as to his skill, treats the case in the sterotyped, and 
routine way; he gets a bad result. Had he used his better judg- 
ment, given his common sense rein and risked the reproach of being 
an innovator, the result would have been different. 

Every case must be studied and treated on its own merits, with 
due regard, of course, to certain general principles. To begin with, 
the prognosis should always be guarded in some degree. As King 
says (St. Paul Medical Journal, August, 1906): "Optimism as to 
the final outcome on the part of the physician is a mistake. Take 
the patient into your confidence, let him anticipate the certainty 
of some permanent defect, so that in the end an imperfect result will 
not reflect so much upon your skill arid will tend to minimize mal- 
practice suits. And how very rarely indeed can the result be per- 
fect. With the very best treatment, there will nearly always re- 
main as the best outcome some slight weakness, or limitation of 
motion, or ache, or pain — -at least a callus as a 'lasting memorial.' " 

The diagnosis of these fractures is usually easy in the large sense, 
as King says, but after all difficult as a whole, for no eye can see the 
injury wrought to the softer tissues. In many cases the position 
will indicate at once that there is a fracture, but one must endeavor 
to learn much more — the possible associated injuries to joints, 
muscles, blood vessels, and nerves. To be able to do this necessitates 
a fairly accurate knowledge of anatomy to begin with, aided by 
systematic examinations, and on this foundation skill grows with 
experience. 

The diagnosis of fracture in the bones of the extremities is based 
on several factors: (a) history of the case, (b) deformity, (c) abnormal 
mobility, (d) pain and loss of function, (e) crepitus, (f) X-ray 
examination. 

(a) It is essential to know how the accident occurred. Frequently 
in the absence of definite symptoms, the diagnosis must rest upon 
the history. For example, in a case of a hip-joint injury in an elderly 
person presenting loss of function and some pain but no other symp- 



202 FRACTURES OF THE EXTREMITIES 

toms, a diagnosis of impacted fracture should be made if it is learned 
the patient fell striking the hip. 

(b) Deformity includes changes in the relations or dimensions of 
the bones and the appearance of the limb. The two limbs must 
always be compared. It must be determined that there has been 
no previous injury to cause the deformity. When both endsr of a 
bone are accessible to touch, it may be readily measured and com- 
pared with its opposite. In the case of the humerus, it is necessary 
to measure from the acromion; in the case of the femur, from the 
ilium. The position which the fragments assume may be due to the 
direction of the force or the action of the muscles. 

(c) Preternatural mobility implies movement in unnatural situa- 
tions or in unnatural degree or direction. As one of the cardinal 
signs of fracture, it has hitherto been assigned too much importance. 
Its presence indicates fracture, but its absence indicates nothing. 
We all know that in impacted fracture, there is no abnormal mobility. 
In fractures of the bones of the tarsus and carpus, in epiphyseal 
fracture, in any fracture where the fragments are small or deeply 
placed, it may be impossible to discover movement without a manipu- 
lation which may be distinctly injurious. In the case of fractures 
near joints, it may be impossible to determine whether the move- 
ment is in the joint or near it. 

The fact is that in most cases where abnormal mobility is 
present, the fracture may be readily diagnosed without reference 
to this sign. 

(d) Crepitus is the almost constant accompaniment of abnormal 
mobility and is the grating produced by the friction of the two 
fragments. It is pathognomonic, but must not be sought for too 
vigorously. It is absent in impacted fracture, and to break up an 
impacted fracture, testing for crepitus, may be a calamity. Crepitus 
may sometimes be heard with the phonendoscope and not with the 
ear. 

(e) Pain and loss of function go together since the pain is usually 
the cause of the loss of function. Both are present in nearly all 
fractures, but often occur in as great degree with contusions. 

The amount of pain varies with the location, but is nearly always 
aggravated by movements or pressure. Taken in connection with 









DIAGNOSIS OF FRACTURES 203 

the history of the case, it is a valuable diagnostic aid. The presence 
of pain may call for anesthesia before the diagnosis can be completed. 

Stimson has recently emphasized the significance of pain in the 
diagnosis of fracture, and indicated the manner in which it may be 
interpreted. Crepitus and abnormal mobility are, to his mind, of 
less importance than pain as a diagnostic aid. 

The search for pain in all doubtful cases should be systematic. 
Begin first with local pressure over the suspected area with the tip 
of the finger or with the rubber end of a lead-pencil. There are 
definite lines of tenderness to be discovered in many of the fractures 
about joints. For example; in Colles' fracture this line can be plainly 
traced across the radius just above the wrist; in fracture of the ex- 
ternal condyle of the humerus, along the external condylar ridge just 
above the elbow; and in fracture of the surgical neck of the humerus 
along the front or outer side of the bone. 

Next test the character of pain elicited by cautious movement of 
the limb. Increased muscular tension thus produced awakens in- 
creased pain at the site of the fracture, and the patient may be able 
to indicate the exact location of the lesion. The effort on the part 
of the patient to produce certain movements is helpful. 

Finally, indirect pressure may be employed: thus, in transverse 
fracture of the tibia, pressure upward on the foot exaggerates the 
pain markedly; and in the same manner, pressure upward at the 
elbow, may assist in locating the fracture in the shaft of the humerus. 
Stimson notes the important exception, that in the case of fracture 
of the neck of the femur forcible pressure upward often fails to cause 
pain. 

In the case of fracture of one of the bones of the forearm or leg, 
squeezing the two bones together will generally help the patient to 
locate his trouble. 

(f) The X-ray cannot be ordinarily available in general practice, 
although of the greatest assistance in cases of doubt. Without its 
use many fractures in the region of joints will be diagnosed as some- 
thing else. Bloodgood particularly emphasizes its value (Pro- 
gressive Medicine, Dec, 1906), believing that the doctor who neglects 
the aid of the Rontgen picture, when he is able to obtain it, will 
have much to regret. There is no danger that its employment 



204 FRACTURES OF THE EXTREMITIES 

will blunt the diagnostic sense, unless, as is often done in hospitals, 
it is used to the exclusion of other aids. The X-ray has at least 
modified our notions as to what constitutes a perfect result in the 
treatment of a fracture. Wherever the X-ray picture is used to 
back up a claim of malpractice by reason of inaccurate apposition 
of fractured bone, we must insist that restoration of form and func- 
tion constitutes a perfect result surgically, whatever discrepancies 
the Rontgen picture may reveal. 

The treatment implies a reposition and an immobilization that 
the bones may unite in their normal relations. It has that ob- 
jective, but has also another which is not necessarily a concomitant 
of the first. The bones must unite without deformity but there 
also must be restoration of the limb's functions. Union in good 
position, then, is only one of the means to a larger end. It is better 
to say that the treatment includes reduction, immobilization, and 
mobilization. 

In making reduction, violence must be avoided. Gentle but per- 
sistent effort is always better than rude haste in overcoming the 
resistance of muscles and ligaments, which is usually the chief 
obstacle to reposition. The line of traction must be adapted to the 
muscular action. Traction must usually be accompanied by counter- 
traction and local manipulation of the broken ends. 

In making traction it should be made directly, if possible, on the 
bone involved, without the intervention of a joint. For example, in 
reducing the humerus the traction should be applied above the elbow 
joint. Often an anesthesia is necessary to relax the muscles, and if 
anesthesia was necessary to complete the diagnosis, everything 
should have been prepared previously for the treatment so that 
only a single anesthesia is necessary for diagnosis, reduction, and 
dressing. 

In the cases of suspected fracture in the vicinity of a joint, it is 
not always best to hurry the reduction; often it is better to wait a 
day or so and try to reduce the swelling, for the swelling aggravates 
the difficulties which are always great in the differential diagnosis 
about the joint; and, if flexion is required, as in the case of 
certain fractures above the elbow, the pressure may shut off the 
circulation. 



TREATMENT OF FRACTURES 205 

So far as the shaft of the long bones are concerned, however, the 
formula should be immediate reduction and fixation. That the re- 
duction has been complete is attested by the appearances of the 
limb, by the absence of any irregularities to the touch, and by the 
coincidence of its measurements with those of the sound limb. 
These comparative measurements should be a matter of routine 
practice. 

Warbasse says (J. A. M. A., March 13, 1909), "the sooner a 
fracture is reduced and held immovable, the less will be the swelling 
and the more satisfactory the result. There is a prevalent notion 
of waiting until the ' traumatic reaction has subsided.' This ancient 
phrase rolls off the tongue sonorously and sounds important, but 
is to be reverently laid aside. Traumatic reaction is going on all 
the time as long as the bones are out of place or so long as they are 
movable. If we can effect immobilization soon enough, the swelling 
will not come up." This is doubtless true in most cases, yet it is 
to be remembered that in spite of reduction of the bones, lacerated 
muscles and ruptured vessels may continue for some time, in some 
cases, to pour their exudate into the tissues to augment the swelling. 
This idea, however, pertains more to the mode of dressing and 
does not refute the doctrine of immediate reduction. 

Immobilization is a phase of treatment raising many questions 
in dispute. In what manner shall it be applied and for how long? 
Or, as Championniere insists, may it not in many cases be dispensed 
with entirely? For he believes that absolute fixation of the frag- 
ments is not the condition most favorable to the processes of repair. 
A certain amount of movement is necessary to the vitality of the 
bone, and therefore movements and massage represent the chief 
elements of his treatment. That it is the best treatment for frac- 
tures about joints no one will deny, even though unwilling to dis- 
pense with fixation in other fractures of the long bones. 

As to the manner in which fixation is to be attained, let it be said 
briefly that the simplest effective dressing is the best. Its elabo- 
rateness will depend upon the tendency for the displacement to re- 
cur, and this tendency must be measured by the degree of obliquity 
of the fracture and the action of the muscles. Sometimes the tend- 
ency to recurrence is an indication of imperfect coaptation. In 



206 FRACTURES OF THE EXTREMITIES 

one case, then, only a light retaining splint is necessary and in 
another it must indeed be firm and strong. 

At the present time there can be no question but that plaster of 
Paris is the dressing of choice. At any rate, it will render the best 
service to the general practitioner who must rely on his own re- 
sources in fashioning splints. Ready-made splints are an abomina- 
tion. There are other plastic materials that are often useful, and 
in lieu of all these materials the splint may be cut into forms to 
suit the case from boards, etc., and applied well padded. (See 
page 48.) 

Walsham formulates the principles which must regulate the 
of splints in any case. 

1. The splints must be well padded. 

2. Pressure must not be made over the points of bones. 

3. Strapping or bandages must not be put on too tightly. 

4. Circular constriction of the limb must be avoided. 

5. The splints, if possible, should reach beyond the joint above 

and below the fracture. 

6. The patient should be seen within twenty-four hours after 

the splint is applied for the bandage may become too tight. 

7. The splints should not be needlessly disturbed — that is to say, 

if the patient is comfortable and the limb in good condition. 

8. Spasm of the muscles is to be overcome by steady extension. 

9. The part below the fracture should be bandaged, or at least 

raised, to prevent swelling and edema. 

The first immobilization will continue till there is no tendency to 
spontaneous recurrence of the displacement, which will vary in 
different cases. After this time a dressing must be used which is 
easily changed, and daily massage must be instituted. Complete 
and continuous fixation through a long period is distinctly bad 
practice and most especially whenever a joint is involved. 

Rossi has shown (Wiener Medical Presse, Jan., 1902) that the 
amount of new cartilage formation is proportional to the amount of 
movement permitted and is found in the greatest amount in fractures 
treated by massage, and is explained by the greater formation of new 
blood vessels and the consequent more active circulation and ab- 
sorption of effusion. 



TREATMENT OF FRACTURES 207 

You will ordinarily, therefore, proceed in something after this 
manner: you will carry out a systematic inspection before handling 
the part, you will observe any deviation of the hand or foot from the 
normal axis of the member and compare the injured with the un- 
injured side. In a large number of cases this inspection will be 
sufficient to diagnose the case. 

Measurements are of great value in many cases and must not be 
overlooked as a diagnostic aid. In the absence of deformity or 
shortening you may proceed next to palpate the affected region in 
order to determine the degree of displacement and other char- 
acters of the fracture. 

Manipulation may occasionally be required to elicit crepitus and 
preternatural mobility but certainly should not be considered a 
routine procedure. In any event handle the injured limb gently, 
never forgetting that the least haste or carelessness may greatly 
aggravate the displacement and the traumatism to the soft tissues 
or change a simple into a compound fracture, not to speak of in- 
creased shock or suffering to the patient. 

Finally, having determined as nearly as possible the conditions 
present, you will assemble the dressings suitable to the case. Once 
these are all prepared, administer the anesthetic. A full relaxa- 
tion is essential for an easy reduction but as the anesthesia pro- 
ceeds the injured limb must be watched by an assistant lest in the 
stage of excitement the patient do himself an added hurt. The 
anesthesia also favors a more detailed diagnosis and a better deter- 
mination of the minutiae of treatment. In a few days the part should 
be skiagraphed and if the position of the fragments is good, the limb 
well immobilized you may consider that a good union is in sight. 

Finally the question of operative treatment is to be considered. 
Whatever advantage plating may possess it cannot be the method 
of choice with the general practitioner. The open treatment, 
therefore, will be reserved strictly for those cases in which either 
reduction or fixation cannot be otherwise accomplished. 

First aid to those disabled with fractured limbs is in civil practice 
more frequently given by others than the doctor. It is desirable, 
however, whenever possible, that he should direct the transporta- 
tion and the preliminary treatment. 



208 FRACTURES OF THE EXTREMITIES 

The utmost care must be practised in lifting and handling the 
broken limb, lest the injuries be augmented and a simple fracture 
converted into a compound. 

If fracture is merely suspected, it must be assumed to be present. 
The limb must never be lifted by the foot or hand but must be 
lifted as a whole, resting upon the palms of the hand. Two at- 
tendants are always better than one in handling a broken leg. If 
the deformity is quite obvious even to the unpractised, an effort 
should be made toward reduction before applying temporary splints, 
this with a view to preventing further injury to the soft parts. 

The limb is seized by an attendant at each end and gentle and 
steady traction made in the direction of its axis. If this does not 
succeed, the attendants must not persist in the effort. It must be 
left for the surgeon. 

If the fracture is compound, with severe hemorrhage, the clothing 
must be removed. Otherwise this is not necessary. In removing 
the trousers or a coat, for example, the sound limb is uncovered first 
and then, very gently, the injured one. It is better to cut the cloth- 
ing or rip along a seam. 

A splint is next improvised from whatever may be first at hand, a 
thin board, laths, an umbrella, or the branch of a tree. The splint 
is padded, or the limb wrapped with whatever presents itself, a 
blanket or anything to prevent undue pressure, and then is fastened 
on the limb by a cord, or belt, or suspenders, etc., and finally the 
injured leg is bound to the sound leg, the injured arm to the side of 
the chest or carried in a sling. 

The limb thus temporarily immobilized, the patient is ready to be 
moved. 

To lift the patient with the greatest safety in the case of a broken 
leg, for example, one attendant standing on the sound side, places 
his arms under the body of the patient, who in the meantime locks 
his arms about the attendant's neck. A second attendant, standing 
on the same side, places one hand under the body, one under the 
sound limb, while a third attendant, facing the others, supports 
the broken limb. At his word of command, all lift. This careful- 
ness must not be relaxed. 

If a litter is available, or one can be improvised, it is placed parallel 



FRACTURES OF THE ARM 209 

with the patient, its feet at his head, so that without any incon- 
venience the patient may be laid upon it. 

FRACTURES OF THE HUMERUS 

Certain points of anatomy apply to nearly all fractures of the arm, 
and are useful in diagnosis and reduction. Recall the relations of 
the humeral head to the acromial and coracoid processes; the loca- 
tion of the greater tuberosity, the internal and external condyles; 
the attachments of several muscles, particularly the deltoid, biceps, 
and triceps; the relations of the musculo-spiral nerve. Remember 
that in the normal relations a line dropped from the tip of the 
acromion to the external condyle will touch the greater tuberosity. 

Nor must one forget the location of the great vessels on the inner 
side of the arm, the proximity of the brachial plexus in the axillary 
space and the intimate relations of the ulnar nerve to the internal 
condyle. 

All these matters must be present in the imagination as the in- 
jured arm is inspected. 

The musculo-spiral groove is a line of least resistance and deter- 
mines many of the spiral fractures of the shaft. 

The age of the patient is of great importance in determining the 
nature of the fracture at the extremities. The difficulties of reduc- 
tion and fixation determine largely by muscular action and accord- 
ingly the musculature must be kept well in mind. 

The symptoms, the deformities, the complications, the treatment 
all vary, depending on the part of the humerus involved; there- 
fore the shaft and the two extremities must be studied separately. 

FRACTURE OF THE SHAFT OF THE HUMERUS 

Direct or indirect violence, a fall on the elbow or wrist, a twist, or 
muscular contraction may produce fracture of the humeral shaft 
which for the present purpose is considered as extending from the 
attachments of the deltoid to the upper level of the condyles (Fig. 

139). 

The line of fracture may be transverse, oblique, or spiral, de- 
pending on the nature of the violence. Thus a blow will more likely 



2IO 



FRACTURES OF THE EXTREMITIES 



produce a transverse; a fall on the elbow, an oblique; a twist of the 
arm, a spiral fracture of the shaft. 

On inspection the broken arm is usually found to be considerably 




Fig. 139. — Fracture of the shaft of the humerus. 



swollen; the deformity marked, only when the patient lies down; 
pain, preternatural mobility and crepitation are easily elicited. 
There is usually shortening as compared with the sound side, meas- 



. 



TREATMENT OF FRACTURES OF THE ARM 



211 



uring from the tip of the acromion to the external condyle and, 
normally, this line lies over the greater tuberosity (Fig. 140). 




Fig. 140. — Testing the humerus for shortening. Measuring from the acromion to the 

external condyle. 



The treatment will depend on the degree of displacement. If 
displacement is absent apply well-padded splints, one internal ex- 



212 



FRACTURES OF THE EXTREMITIES 




Fig. 141 



The patient is seated; bandage the injured member from the wrist to about 3 inches 
above the elbow; protect the axilla with absorbent cotton; flex the forearm at a right angle 
and maintain in that position in a sling. Pass a band under the axilla and fasten it to some- 
thing (a hook in the wall), so that the shoulder is slightly lifted. That is the counter- 
extension. 

Another band crosses the forearm just below the bend of the elbow and to it is attached 
a weight, say of 2 K. G., that is the extension. Give the apparatus a little time and it will 
effect a reduction as the muscles tire. Employ this interval to prepare the fixation dressing. 

Cut out sixteen strips of crinoline, each about 1 yard long, and wide enough to cover the 
arm at its thickest part. Lay these strips one upon the other, and fasten them together; 
and from the sheet thus formed, cut a deep scallop out of either end — at the lower end 45 to 
50 cm. and at the upper end 15 to 20 cm. deep. Of the yokes thus formed, one will fit into 
the axilla and the other into the bend of the elbow, while the intermediate portion forms an 
internal splint for the arm. 

Soak the cloth in liquid plaster and apply it in the manner indicated, molding it carefully 
to the arm. The two upper bands overlap the shoulder and the two lower ones are wound 
spirally around the arm to the wrist. In this way the shoulder and wrist are immobilized. 
In the menatime the extension and counter-extension are not disturbed until the plaster split 
is fully hardened. The dressing may be further secured by a few turns about the chest. 



TREATMENT OF FRACTURES OF THE ARM 213 

tending from the axilla to the bend of the flexed elbow the other ex- 
ternal from the acromion, below the elbow. These splints are held 
in place by adhesive strips and the whole firmly bandaged. 

If, on the other hand, the displacement is conspicuous, it may be 
difficult to reduce, difficult to hold. A number of procedures are 
available; the patient may be anesthetized, the fracture reduced by 
strong traction, the patient's shoulder then brought well over the 
edge of the table, the extremity bandaged with glazed cotton and a 
plaster roller applied, including the wrist and shoulder. The pa- 
tient must stay in bed. Instead of the plaster roller, plaster splints 
may be applied on the same principle as the wooden splints de- 
scribed above. 

Hennequin's dressing is strongly recommended by Lejars. Its 
purpose is to reduce the fracture without anesthesia and to maintain 
the reduction until an internal splint is applied (Fig. 141). 

Union requires from six to eight weeks; failure to unite is usually 
due to the interposition of the soft parts. The importance of the 
musculo-spiral nerve in this connection must never be forgotten. 
Paralysis of this nerve occurs in about 8 per cent, of such fractures; 
it may be immediate or remote, depending on whether the nerve is 
itself injured by the traumatism or whether it is caught in the scar 
tissue. The recognition of this injury is imperative. Inclusion of 
the soft parts which cannot be remedied calls for an open operation. 

FRACTURE OF THE UPPER END OF THE HUMERUS 

These injuries often offer the very greatest difficulties in diagnosis. 
Such cases for the most part present themselves with swollen, painful, 
and contused shoulders, perhaps deformed, and functionless. You 
ask yourself: is it only a severely bruised joint; is it a dislocation or a 
fracture of the surgical neck, or perhaps both; or is it an impacted 
fracture of the anatomical neck; are the soft parts implicated? 

Do not waste time in vague palpations but proceed at once to a 
systematic examination, under anesthesia, if necessary. Begin by 
locating the apex of the acromion; if there is no depression beneath 
it; if the thumb cannot be pushed into a concavity but comes in 
contact as it should with the humeral head, you may conclude there 
is no dislocation. With the thumb still in front, close the fingers on 



214 



FRACTURES OF THE EXTREMITIES 



the posterior aspect of the head of the humerus, and with it thus held 
firmly, attempt rotation of the arm. The humeral head rotates with 




Fig. 142. — Examining the shoulder. Rotating head of humerus. 



The head of the humerus is grasped between ringers and thumb of one hand; the other 
moves the patient's forearm through an arc. 

In the case of dislocation the rotation is produced with difficulty, if at all. 

In case of fracture of the anatomical neck the joint is much thickened but there may 
be slight rotation of the head. Fracture of the surgical neck: the arm is freely moved, 
but the head does not rotate. 



TREATMENT OF FRACTURES OF THE ARM 215 

difficulty in dislocation; it does not rotate at all if there is fracture, 
and besides, there is crepitation (Figs. 142, 143). 

A source of error: If the lower fragment overrides much, its rota- 
tion might be felt and mistaken for the humeral head. Abduct the 
arm; easily done in fracture, with increase of deformity and pain. 
Pain is also produced by pressure upward at elbow and by local 
pressure over the front and outer side of humerus. 




Fig. 143. — Examining the shoulder. Comparing the relations of the coracoid processes. 

Examine the axillary space and all the other aspects of the 
shoulder, comparing the two sides; and compare the other landmarks 
of the arm. Do not begin any treatment until the diagnosis is assured. 
How unfortunate it is to attempt reduction of a supposed dislocation 
by the ordinary method when it is complicated by fracture; or to 
treat as a contusion, a fracture with displacement! 

To consider briefly the more common findings of such exami- 
nations: 



2l6 



FRACTURES OF THE EXTREMITIES 






i. Fracture of the surgical neck without overriding (Fig. 144) needs 
only the simplest treatment: Brace the arm on the inside with a 
" V " shaped axillary pad, and with the forearm flexed at a right angle; 
support the whole extremity in a sling of the Mayor type. Addi- 
tional protection may be afforded by a shoulder cap (Fig. 145). 
Begin massage early. 







Fig. 144. — Fracture of 
surgical neck of humerus. 
(Moullin.) 



Fig. 145. — Fracture of surgical neck. Axillary- 
pad; shoulder cap; forearm supported in sling. 
(Scudder.) 



2. Oblique Fracture of the Surgical Neck with Much Overriding. — 
These are difficult to reduce; difficult to maintain; likely to be mis 
taken for dislocation (Fig. 146). 

Reduction. — In making traction, draw downward and outward at 
first and then in the axis of the limb. Do not stop until the arm is 
the correct length by measurement; until the subcoracoid projection 
has disappeared; until the acromion, greater tuberosity and the ex- 
ternal condyle are in the same straight line. Extension must be 



I 



TREATMENT OF FRACTURES OF THE ARM 



217 



maintained while the dressing is applied or the displacement will 
certainly recur. 

The arm must be fixed in abduction and with the elbow slightly 
forward; only in this position will the lower fragment coapt with 
the upper which, of course, the fixation apparatus will not affect. 
Either the patient must be put to bed and extension with weight and 
pulley applied or else the rather complicated splints of the type used 




Fig. 146. — Fracture of surgical neck with overriding. 

by Heitz-Boyer or Dupuy must be employed to maintain these 
positions. In either case the fixation must not be prolonged, and 
massage and passive movement begun early. If the circumstances 
permit, the open operation gives by far the most satisfactory result. 



FRACTURE OF THE SURGICAL NECK WITH DISLOCATION 

This is a very serious injury; difficult of diagnosis; of bad prog- 
nosis. Carrying out the systematic examination described, you find 
the head displaced, but the arm is not fixed in abduction as in the 



218 



FRACTURES OF THE EXTREMITIES 



ordinary dislocation; it drops to the side. Again, the head does 
not rotate with the arm; there may be crepitation; from these and 
other confirmatory points the diagnosis is made. 

Reduction. — Anesthesia is necessary. Make a slow, gentle, but 




Fig. 147. — Fracture with dislocation before reduction. 



persistent traction on the arm; this combined with manipulation of 
the head of the humerus in the axillary space may succeed in re- 
storing the head to the glenoid fossa, for more than likely the 
head is still attached to the shaft by periosteum and muscular 
fibers. As the assistant makes the traction apply your thumbs to the 



TREATMENT OF FRACTURES OF THE ARM 



2I(J 



head in axilla and, with the fingers braced by the shoulder, try to 
force the head into place (Figs. 147, 148). 

Once the dislocated head is reduced, reduce and treat the fracture 




Fig. 148. — Same fracture of surgical neck with dislocation after reduction. 

by the ordinary means. Massage must be begun especially early. 
If these efforts fail, choice lies between operation and expectant 
treatment. 



2 20 FRACTURES OE THE EXTREMITIES 

The expectant treatment may give a surprisingly good result 
in case the dislocated part includes only the head. With early 
massage and passive motion a new joint is created, the upper end of 
the shaft adapting itself to the glenoid cavity. 

In case the dislocated fragment includes the surgical neck a 
persistently stiff shoulder may be expected and not only that but a 
large callus may seriously interfere with the brachial plexus, or even 
the axillary vessels. 

Royster, of Raleigh, N. C. (Journal A. M. A., Aug. 10, 1907), re- 
views his own experience and the literature dealing with this condi- 
tion, and concludes very logically that operative treatment in the 
great majority of cases is alone effective. 

The preferable incision begins at the acromion process, extends 
vertically downward as far as necessary, and aims to reach the bone 
by passing between the pectoralis major and the deltoid. The head, 
thus exposed, is to be reduced by manipulation, although oc- 
casionally a special hook or bone forceps may be necessary. Wiring 
will seldom be required except in the cases operated late. The dress- 
ing should be applied so as to maintain the arm in abduction. 
Royster believes in immediate operation, regarding such cases as 
emergencies, as much so as strangulated hernia or appendicitis. 
"Even in cases of doubt, it is preferable to expose the parts to view 
rather than to wait in the hope that nature and time will clear it up." 
Our own experiences seem amply to confirm this view. 

TRACTURE OP THE ANATOMICAL NECK 

This fracture nearly always results from falls upon the point of 
the shoulder and in consequence is impacted. A fall upon the elbow 
may produce an impacted fracture of the upper end of the surgical 
neck but only the X-ray could make the distinction. Great 
swelling and ecchymosis are prominent characters and loss of func- 
tion is complete. Palpation and manipulation reveal nothing but 
the degree of pain. 

The X-ray picture usually shows the head turned either forward 
or backward and an irregular dentated line of fracture. The treat- 
ment from the first is massage and passive motion. 



TREATMENT OF FRACTURES OF THE ARM 221 

The massage of the first two days should be chiefly friction; later 
kneading will hasten the absorption of the exudates. The passive 
motion consists of gentle flexion and extension and the treatment 
must not be such as to aggravate the pain. The daily treatment is 
followed by fixation in a sling. 

After a couple of weeks the treatment may be carried on more 
vigorously and as soon as the patient can move the joint actively he 
must be directed to keep at it many times each day. The first 
movement to return is the antero-posterior; a little later, rotation; 
and last of all abduction. Often times in these cases, in spite of sys- 
tematic treatment the motion is imperfect and the tenderness per- 
sistent, especially over the acromion, the coracoid, and deltoid 
tubercle. 

Fracture of the greater tuberosity may occur as the result of either 
direct or indirect violence, such as fall upon the hand with arm 
extended. The displacement of the tuberosity may be upward, out- 
ward, and backward. Early disability and swelling are prominent 
symptoms; crepitus may be absent. Pain is produced by local 
pressure. Taylor, of New York, asserts (Annals of Surgery, Jan., 
1908) that in uncomplicated cases with moderate displacement 
recovery may be practically perfect without the use of splints, 
massage, or special movements, but on the whole the best result will 
be obtained by immobilization or abduction to a right angle with 
external rotation. 

FRACTURE OF THE UPPER END OF THE HUMERUS IN CHILDREN 

With respect to diagnosis and treatment, fractures of the upper 
end of the humerus in children present some special features. 
Practically speaking, there are but two types of injury; fracture of the 
surgical neck and separation of the epiphysis. The head and 
anatomical neck are immune by reason of their spongy character. 

If the surgical neck is fractured without displacement of the 
fragments or with impaction, the pain, loss of function and de- 
formity are moderate. Usually there is considerable swelling. The 
treatment is simple; fixation in a sling for a week and thereafter 
frequent and gentle passive motion without massage and the func- 
tions of the joint are rapidly restored. 



222 FRACTURES OF THE EXTREMITIES 

If on the other hand there is much displacement, the deformity is 
quite constant, the joint is thickened in front and externally and the 
end of the lower fragment bulges the subcoracoid area. This might 
be taken for the head of the humerus, but on palpation the head is 
found to be in the glenoid cavity. The shortening of the shaft of the 
humerus and the abnormal direction of its axis point to the nature of 
the injury. 

These same signs and symptoms characterize separation of the 
epiphysis but this lesion is much the more serious for improper 
treatment may result in checking linear growth. 

The treatment is the same for the two conditions. Reduction 
requires a general anesthesia and a definite maneuver. 

Make strong traction on the abducted arm, dircting the assistant 
to press outward with his thumbs against the broken ends which form 
with each other an angle pointing toward the coracoid. If the arm is 
now brought to the side the deformity recurs; on that account there- 
fore the arm is to be fixed in abduction. This may be accomplished 
by plaster splints; still better by a plaster dressing including the 
thorax. A part of this dressing is applied previous to the anesthesia 
and reduction. 

The patient is seated and a plaster jacket applied, including the 
shoulder but not the arm. 

The patient is then anesthetized and the fracture reduced. 

The arm is held in abduction and in a forward position, the 
forearm flexed to a right angle and semiprone. A plaster roller is 
now applied, including the shoulder, the arm and forearm. By this 
means you fix the scapula and relax the abductor group of muscles 
which act upon the upper fragment; in this manner the normal axis 
of the humerus is maintained. 

After two weeks remove the plaster and for the next two weeks 
carry the arm in a sling, and function is soon restored. 

FRACTURES OF THE LOWER END OF THE HUMERUS 

Injuries about the elbow are always to be regarded seriously. 
They occur much more frequently in children and are usually due 
to falls upon the flexed elbow. Scudder insists that even in the 
apparently trivial cases the examination should be made under 



TREATMENT OF FRACTURES OF THE ARM 



223 




Fig. 149. — Examining the elbow; locating the three cardinal points — the internal condyle, 
the tip of the olecranon and the external condyle. 

When the elbow is flexed at a right angle the three points stand for the corners of an 
equilateral triangle; when the elbow is extended the three points are in a straight line. The 
head of the radius is easily felt on the normal joint one-half to three-quarters of an inch 
below the external condyle. Gently rotating the forearm helps to locate the capitellum. 

The gutter behind the external condyle is broad and shallow; on the ulnar side deeper, 
containing the ulnar nerve. 



2 24 FRACTURES OF THE EXTREMITIES 

anesthesia, for only by that means, as a rule, can the injury be 
exactly diagnosed. 

The diagnosis itself is chiefly a matter of applied anatomy. The 
landmarks and the normal relations must be clearly in mind. Ob- 
serve on the sound side the relations of the internal and external 
condyles, the olecranon, the head of the radius. It is uncertain at 
first whether it is a contusion, or dislocation, or fracture. Even 
when sure that the case is a fracture, yet it is to be determined whether 
it is supracondylar, or condylar, or some combination of the two. 

Scudder formulates a routine mode of procedure in making the 
diagnosis. 

Observe the character of the swelling — whether general or 
localized. 

Observe the carrying angle. 

Palpate the external and internal condyles. 

Palpate the olecranon process and head of the ulna. 

Rotate the head of the radius. 

Note the relation of the three bony points in extension and flex- 
ion (Fig. 149). 




Fig. 150. — Supra-condylar fracture of humerus. Note obliquity. (Moullin.) 

Determine the possible movements of the elbow-joint. Make 
measurements. Make pressure with the point of the finger to locate 
a painful line which marks the fracture. If the X-ray is used it 
should show both the lateral and antero-posterior view. 

Certain forms of injury are found most frequently: (1) Supra- 
condylar fracture, (2) fracture of one of the condyles, (3) multiple 
fracture involving the joint. 



TREATMENT OF FRACTURES OF THE ARM 



225 




Fig. 151. — Extension fracture; slight backward 
displacement of elbow. 



(1) Supra-condylar Fracture. — This type occurs more frequently 

in children. The joint is not usually involved, the plane of fracture 

extending commonly from 
above downward and for- 
ward. The displacement of 
the upper fragment, there- 
fore, is downward and for- 
ward, and if union takes 
place in this position the 
flexion of the elbow is much 
abbreviated (Fig. 150). 

This is the so-called " ex- 
tension " fracture (Fig. 151); 
whereas in the "flexion" 

fracture the lower fragment is displaced upward and forward (Fig. 

152). It must be definitely determined which form exists. 
The extension fracture, by the 

far the more frequent, simulates 

backward dislocation but you 

find the condyles, the olecranon 

and the head of the radius in 

their normal relations to each 

other. The condyles may be 

moved independently of the 

shaft and measuring from the 

acromion to ext. condyle you 

will probably find some short- 
ening and also the normal axis 

is disturbed. 

Compared with the other joint 

there is no change in width which 

excludes intercondylar forms. 
Along with the ordinary signs 

Of fracture the Sharp end Of the Fig. 152.— Supra-condylar fracture: forward dis- 
Upper fragment may be felt in Placement of elbow. ("Flexion fracture.") 

the flexure of the elbow. 

Imperfect reduction of these fractures leads to some loss of move- 
15 




226 



FRACTURES OF THE EXTREMITIES 



ment and awkward deformity; and in many instances to nerve 
complications, the result of a large callus. A "wristdrop" for ex- 
ample may gradually develop in such a case the result of inter- 
ference with the musculo-spiral. 

Still more important, if the fracture follows the epiphyseal line 
the child's arm never attains its normal growth. How greatly 
necessary then that we recognize not only the type of fracture 





Fig. 153. — Epiphyseal fracture of 
humerus; backward displacement of 
elbow. 



Fig. 154. — Fracture and complete dis- 
location of the epiphysis, lower end of 
humerus. 



but the variations as well and that we know how to proceed so as 
to restore form and function to the near-normal. And this is by no 
means always easy even when the X-ray has exposed the details 
of the bone disturbance (Figs. 153, 154). 

Three displacements are to be overcome: (a) An antero-posterior 
which uncorrected leads to interference, with flexion and extension; 
(b) lateral, affecting the carrying angle; and (c) rotation, affecting 
the supinator function. 

Ordinarily you will proceed in this manner: direct the assistant 
to make strong traction on the extended forearm, gradually chang- 
ing the extension to acute flexion and while he does this, you will 



TREATMENT OF FRACTURES OF THE ELBOW 



227 



make counter- traction on the humerus grasping it above the line 
of fracture so as to pull on the shaft and at the same time push against 
the olecranon with the thumbs . Grinding and tearing, the lower 
fragment is felt to move forward. Traction and counter-traction 
must be maintained on the flexed elbow while by manipulation the 
lateral displacement and rotation are overcome (Fig. 155). Fixa- 




Fig. 155. — Supra-condyloid fracture of the humerus. Method of reduction before ap- 
plying retentive splint. Counter-traction on upper arm. Traction on condyles of hu- 
merus with right hand; backward pressure with thumb of left hand. Also illustrative of 
method of beginning acute flexion. (Scudder.) 



tion in forced flexion may be secured by encircling bands of ad- 
hesive or still better, we think, by a posterior plaster splint made as 
follows: 

Twelve to sixteen pieces of crinoline long enough to reach from the 
deltoid insertion to near the wrist, and wide enough to cover the 
arm, are quilted together and two oblique notches cut corresponding 
to the bend of the elbow. This piece of padding is now impreg- 
nated with liquid plaster and applied to the back of the arm and fore- 
arm, and well molded (Fig. 156). The two notches permit a ready 
adjustment at the bend of the elbow. The support of the arm is not 



228 



FRACTURES OF THE EXTREMITIES 



relaxed until the plaster has hardened. The gutter thus formed may 
be strengthened by a loosely applied roller which passes from the 

wrist across to the arm near the axilla, 
around it and back to the wrist again, 
and so on. The arm is thus fixed in acute 
flexion (Fig. 157). Immediate reduction, 
immediate fixation in forced flexion is the 
correct formula therefore for this type of 
injury. But the case may be seen late and 
the swelling be of such degree that flexion 
is out of the question because of interfer- 
ence with the brachial vessels, something 
which must be watched whatever the form 
of treatment. 





Fig. 156. — Fracture of the 
elbow in the child: pattern for 
plaster splint. Notched so that 
when the elbow is flexed splint 
may be easily molded. 



Fig. 157. — Fracture of elbow in the child: plaster 
splint molded to the flexed elbow. 



A boy of twelve years was brought in from the country with an 
injury received the day before by being thrown from a horse. A 
diagnosis of fracture about the elbow had been made, and with it 



TREATMENT OF FRACTURES OF THE ELBOW 229 

the effort to fix the arm in forced flexion. The whole member was 
greatly swollen, edematous about the elbow with blebs in process of 
formation. The X-ray confirmed the diagnosis, showing epiphyseal 
separation with fracture and separation of the internal condyle. 
The dressing was removed, the arm fixed in extension; daily light 
massage was instituted to remove the tumefaction, and after 
four days an effort was made to reduce the fragments and put the 
arm in forced flexion; but this only resulted in complete obliteration 
of the radial pulse. The arm was left in semiflexion and pronation, 
and very light massage was again instituted for a few days; gradually 
the swelling subsided, and after the end of a week more another 
effort was made to reduce under general anesthesia, with better 
results. After a week of fixation in the corrected position the mas- 
sage was begun again and continued for some weeks. Eventually 
the restoration of function was almost complete. 

Massage in the case of these elbow injuries in children is likely to 
do more harm than good and should have for its only object the ab- 
sorption of the exudates. Too freely used, it overstimulates the 
new bone formation and produces excessive callus which in this case 
we wish particularly to avoid lest the olecranon and coronoid fossae 
be obliterated. Nor need we concern ourselves too much with 
passive motion. If the joint surfaces are free we may expect the 
child gradually and unconsciously to increase the amplitude of the 
movements and in one to five months a practical restoration of 
function is the rule. Finally there is to be mentioned the occasional 
case which comes in two or three weeks after the accident with the 
fragments unreduced and at this time irreducible. Such cases are 
by no means hopeless for the bone may be exposed, the periosteum 
turned back, the fragments pried apart, the callus chipped away and 
the raw bone surfaces adapted; the limb fixed in flexion and there- 
after treated as a primary fracture. 

FRACTURE OF THE EXTERNAL CONDYLE 

This accident is not infrequent in children, due to fall upon the 
outstretched hand the force being transmitted through the radius 
to the condyle. In the adult a direct force is required. 

The diagnosis is easy before much swelling occurs; after that it 



230 



FRACTURES OF THE EXTREMITIES 



can be made with certainty only by the X-ray. The ecchymosis, 
the pain on pressure, the limited flexion, and painful supination, 
point to the nature of the injury. 

The fragment may be displaced upward or downward and may 
be rotated as well. (Fig. 158.) 




Fig. 158. — Fracture of the external 
condyle in the child. 



Fig. 159. — Fracture of internal 
condyle. (Moullin.) 



Reduction, sometimes difficult, is accomplished by manipula- 
tion and the arm is to be put in plaster in either extension or flexion 
depending upon which holds the fragment in place. The dressing 
should be removed about the end of the second week and the child 
encouraged to use his arm. In one or two months the junction will 
be nearly restored. Massage as mentioned before is not desirable 
in fractures about the elbow. 



FRACTURE OF THE INTERNAL CONDYLE 

This fracture is not nearly so frequent in children as the supra- 
condylar form or even fracture of the external condyle because the 



TREATMENT OF FRACTURES OF THE ELBOW 



231 



force of a fall on the hand is much more likely to be transmitted 
through the radius which abuts on the external condyle (Fig. 159). 

In the adult, however, the internal condylar fracture is the 
more frequent and is due to direct violence. 

It derives its importance from the loss of joint function, the 
muscular disability, or the nerve complications which may ensue. 




Fig. 160. — Fracture of the internal condyle with backward dislocation of elbow. 



The movements of the olecranon process are likely to be impaired, 
the ulnar nerve likely to be compressed by the callus; the flexor group 
of muscles attached thereto impaired by the shift in their point of 
attachment. 



232 



FRACTURES OF THE EXTREMITIES 



The symptoms and signs of fracture of the external condyle 
apply with equal force here. Practically the same mechanical 
principles operate to produce displacement, rotation and tilting of 
the fragments. 

The diagnosis is to be made from these symptoms and signs, 
coupled with the physical examination. 

It may be readily mistaken for a backward dislocation, for if the 
head of the radius is out of place the fragment may move backward 

carrying the ulna with it. In the 
case of children there may be actual 
dislocation along with the fracture 
(Fig. 160). 

The X-ray will confirm these find- 
ings. The treatment, if no displace- 
ment exists, is simple; firm bandag- 
ing and the forearm fixed at a right 
angle in a sling. 

If the displacement is marked the 




mmm 





Fig. 161. — Intercondylar fracture 
of humerus. (Moullin.) 



position of fixation will be that 
which best maintains the reduction. 
Usually this will be flexion since 
thereby the attached muscles are 
relaxed. 

After a few days gentle passive 
motion should be practised as the 
best means of molding the forming 
callus and keeping the fossae clear. In the course of a few months 
the joints functions will be normal. If the fracture is complicated 
by dislocation, this may be easily reduced by traction in extension 
and subsequently fixing the elbow in forced flexion. 

If flexion is much limited it is certain that the fragment is locked 
in the joint and an open operation should be practised without delay. 
(3) The intercondylar and multiple fractures involving the joint, 
as they do, require a very guarded prognosis (Fig. 161). By referring 
to the landmarks, the displacements are to be figured out and the 
fragments are to be manipulated until all the movements of the 
joint are restored. 



TREATMENT OF FRACTURES OF THE ELBOW 233 

The forearm is then to be acutely flexed and fixed either by the 
adhesive strips or plaster splints as before described. If the dis- 
placements cannot be held by this means the fracture must be 
treated by extension for a few days and then put up in acute flexion. 
Massage and passive motion must be very early begun in these cases 
and persisted in for a long time. 

FRACTURE OF THE OLECRANON 

Following fractures of the lower end of the humerus, fractures of 
the olecranon should be next considered for the same anatomical 
features are to be recalled in diagnosis. The diagnosis of this 
fracture has no particular feature but is to be made by inspection, 
palpation of the landmarks mentioned and by manipulation. 
This break is usually due to direct violence, sometimes to muscular 
action. The amount of separation of the fragments depends upon 
the amount of the tear in the fibrous attachments of the triceps, and 
is, of course, most marked in flexion, and is increased by swelling of 
the joint. A complete fracture opens into the joint. 

As to the treatment it is obvious that no one method is equally 
applicable to all cases. There can be no doubt that the method of 
choice, where it is possible, is suturing. 

If this is not advisable, or not permitted, the next best procedure 
is the treatment by massage begun immediately — and this whether 
there is much or little separation. No immobilization, only massage. 

If asepsis can be assured or if the fracture is compound, suture is 
indicated. The operation is not difficult. The bone is exposed by a 
transverse incision, or if there is a wound it may be enlarged. Cleanse 
the wound of all exudates and trim away the ragged tissues; next 
expose the fracture, separate the fragments and expose and cleanse 
the joint. 

There are several methods of suture. If the fracture is transverse, 
the periosteum on each side is laid back and two holes drilled in each 
fragment for the passage of two silver wires. When a wire is passed 
its ends are twisted and the coaptation perfected. The drill holes 
should not involve the cartilage. The wires are cut short and ham- 
mered down smooth, and the periosteum and fibrous sheath sutured, 
and the skin wound repaired without drainage. The arm is im- 



234 



FRACTURES OF THE EXTREMITIES 



mobilized in flexion for eight or ten days and then massage is begun. 
The main object of which is to prevent permanent contraction of 
the triceps. By this means the fragments are kept as nearly as 
possible in contact but even in the most favorable cases the union is 
merely fibrous. 

If the fragments are split, they may be each perforated from 
without inward and a suture passed and tied on the outer side. By 




Fig. 162. — Suture of the olecranon. The suture in the form of a transverse loop 
perforates the lower and two upper fragments. (Schwartz.) 



this means the fragments are all drawn into coaptation. If the 
upper fragment is small the upper transverse perforation may involve 
only the tendon. 

A carpenter fell from his ladder, striking the point of his elbow 
upon the sharp edge of a timber. The joint was laid wide open, the 
olecranon broken across transversely and split as well. At the 
Deaconess Hospital the joint was cleansed thoroughly with normal 
salt solution, the mangled tissue trimmed away. The fragments 
were exposed by free use of the rugine. Two transverse holes were 
drilled, the upper one including bothfragments (Fig. 162). Chromi- 



FRACTURE OF THE OLECRANON 



23S 



cized catgut was used to draw the fragments together. The single 
suture was quite sufficient to secure coaptation. A small drainage- 
tube was left in the joint cavity. The periosteum was repaired 
(Fig. 163), and the soft parts closed with additional drainage. 
After the third day, the tube in the joint cavity was removed 
permanently. There was a little suppuration in the soft parts and 




Fig. 163. — Suture of the olecranon. Repairing the periosteum by a continuous 

catgut suture. {Schwartz.) 



the superficial drainage was retained for a week. At the end of ten 
days the soft parts being healed, the position of the elbow was 
changed from extension to flexion and daily passive motion and mas- 
sage was begun. The result was perfect use of the joint. 

J. B. Murphy has devised and recommends a method of subcu- 
taneous suture (Jour. Am. Med. Assn., Jan. 27, 1906). Begin by 
making a small incision over the external border of the olecranon 



236 FRACTURES OF THE EXTREMITIES 

below the line of fracture. Through this small opening (iH inches) 
drill the olecranon transversely, and over the point of emergence of 
the drill on the inner border of the olecranon incise the skin again. 
An aluminum-bronze wire is passed through the drill-hole from 
without inward and the inner end is pushed up under the skin along 
the internal border of the olecranon to the level of the apex of the 
bone. At this level another incision is made, the end of the wire 
recovered and pushed through the tendon of the triceps from within 
outward. A fourth small incision is made over the end of the wire to 
the outside, and the end of the wire again directed under the skin to 
the starting point and there tied tightly, in that manner approxi- 
mating the fragments. Close the skin wounds. 

FRACTURE OF THE HEAD OF THE RADIUS 

Another fracture not infrequent should be considered in con- 
nection with injuries about the elbow and that is fracture of the head 
of the radius. It is the result of direct violence, or indirectly by falls 
upon the hand. The fracture is usually vertical, much or little of 
the articular surface being broken off. It derives its importance from 
the fact that it may interfere with all the functions of the elbow-joint 
— -flexion, extension; rotation, supination. The diagnosis will 
usually require the X-ray; nevertheless the absence of change in 
the landmarks along with swelling and tenderness and especially the 
pain on supination and pronation should point to the character of the 
break. Sometimes crepitation may be felt by pressing the thumb 
over the radio-ulnar joint while rotating the forearm. 

The treatment required will most frequently be excision of the 
fragment followed by two weeks' fixation in semipronation, and after 
this passive motion. The results are good. 

The neck of the radius may be broken in much the same manner. 
The lower fragment is drawn upward by the biceps. Flexion of the 
forearm combined with traction and manipulation will effect a 
reduction and the forearm which is flexed for two weeks in flexion 
and semisupination. The point is to keep the biceps from acting 
on the lower fragment (Fig. 164). 



FRACTURES OF THE SHAFT OF ULNA AND RADIUS 237 
FRACTURES OF THE FOREARM 

Fractures of the shaft of the ulna and radius are of the greatest 
importance because of the possible evil consequences, immediate 
or remote. The chances of gangrene, of deformity, of anchylosis 
or paralysis are never slight. This prospect of a crippled or useless 




Fig. 164. — Fracture through neck of radius. Head displaced, requiring excision. 

arm or hand must put us on our guard. There are several anatomical 
points to be kept in mind as regulating both the diagnosis and treat- 
ment. The relative position of the two bones in the stages of rota- 
tion; the attachments of the biceps, the supinator, and the pronators 
and their pull upon the fragments; the interosseous membrane; the 
variations in relative size and strength of the two bones at different 
levels; these are all factors to be taken into account in the study of 



2 3 8 



FRACTURES OF THE EXTREMITIES 



the mechanism of these fractures. They are produced by direct or 
indirect violence; in the latter case, most frequently by falls upon 
the hands, but it is to be noted that such accidents are more likely to 
produce, in the adult, a Colles's fracture; in the child, a supracon- 
dylar fracture of the humerus. The middle third of these bones is 
most likely to suffer, the radius breaking at a higher level than the 

ulna. The radius loses strength up- 
ward; the ulna, downward (Figs. 165, 
166). 

Deformity and displacement may 
exist in any degree. Thus one bone 
may be broken completely, a green-stick 
fracture occur in the other. There may 
be only a slight angulation, or some 
lateral displacement or extreme overrid- 
ing. Naturally, fracture of both bones 
presents the worst prognosis. The dis- 
placements of the radius are always the 
more difficult to manage because of the 
tendency of the two fragments to rotate 
in different directions. 

Thus the upper fragment is rotated 
outward by the biceps; and the lower, 
inward by the pull of the two pronators. 
The diagnosis is not difficult. The patient presents himself sup- 
porting the injured arm which tends to turn inward below, and out- 
ward above. Pain, deformity, mobility and perhaps crepitation are 
present. Lateral pressure wherever applied excites pain at the site 
of fracture. Comparative measurements in the case only one bone is 
fractured will show but little shortening; or, if there is much shorten- 
ing it is certain the other bone is dislocated at the elbow. For ex 
ample, isolated fracture of the ulna with overriding is accompanied 
by forward dislocation of the head of the radius. 

Treatment. — Whether one shaft is broken or both, the principles 
of treatment are the same. Principally, it is obliteration of the 
interosseous space which must be guarded against, lest pronation 
and supination be lost. The contrary rotation of the two fragment 




Fig. 165. — Fracture of both bones 
of forearm due to crushing injury; 
in this case the fracture of the radius 
is at the lower level. 



e 

: 



TREATMENT OF FRACTURES OF THE FOREARM 



239 



of the radius determines the position in which the forearm must be 
fixed. 

Complete supination fulfills these two main indications; it separates 
the shafts most widely; it permits the lower fragment of the radius 




Fig. 166. — Fracture of the shaft of ulna with separation of the epiphysis; fracture 
of the shaft of the radius, too high for a Colles' fracture. 



to fall in line with the upper which is fixed by the pull of the biceps. 
Reduction presents no special difficulties, theoretically, but a perfect 
coaptation is seldom secured. Nevertheless an excellent functional 
result is the rule. Under anesthesia, with the forearm supinated and 
flexed, strong traction and counter-traction aided by manipulation 



240 



FRACTURES OF THE EXTREMITIES 



of the fragments, will bring them into place. Maintaining the trac- 
tion and supination, the dressing is applied. The simple anterior- 




Fig. 167. — Anterior and posterior splint for forearm. (Heath.) 

posterior splint (Fig. 167) is of little use, except in isolated fracture of 
the ulna, because it does not maintain supination. Whatever dress- 
ing is used, it must have one negative character; it must not compress 




Fig. 168. — Method of supporting arm while applying plaster bandage. 



the forearm laterally lest the bones be forced together and the inter- 
osseous membrane be obliterated. A plaster bandage may be used 
including the supinated forearm, the wrist and elbow (Figs. 168, 169). 



TREATMENT OF FRACTURES OF THE FOREARM 



241 



A molded plaster splint is still better, fashioned in this manner: 
Twelve to fifteen layers of crinoline are cut in the form of an irregu- 
lar quadrilateral long enough to reach from the axilla to the palm 
and wide enough to encircle the arm are loosely quilted together to 
form a splint. It is notched where it is to support the elbow and a 
hole cut near one border for the thumb. The splint is soaked in 




Fig. 169. — Fracture of forearm. Plaster-of-Paris splint 
applied. Elbow at right angle. (Scudder.) 

liquid plaster and then molded to the posterior surface of the arm 
and finally fixed with a loosely applied roller. This is the best 
dressing for children. In the case of adults it may be necessary in 
some instances to apply extension to prevent overlapping. 

In any event extreme care must be taken to prevent compression 
of nerves and arteries lest an ischemic paralysis occur. 



FRACTURES OF THE LOWER END OF THE RADIUS 

Certain landmarks about the wrist are useful in diagnosis of in- 
juries in this region. 
16 



242 



FRACTURES OF THE EXTREMITIES 



The styloid processes are easily palpated, the radial styloid lying 
nearer the joint line. The radio-carpal joint line is indicated on the 
anterior surface by the higher of three transverse creases. In 
supination, the styloid of the ulna lies in the plane of the posterior 
surface while the radial lies nearer the anterior plane. The radial 
styloid can be best felt in the depression at the base of the thumb, 
between the long and short extensior tendons. The two wrists 








Fig. 170. — Typical Colles' fracture; 
impacted fracture of lower end of radius 
and fracture of styloid process of ulna. 



Fig. 171. — Colles fracture; marked impac- 
tion, lateral displacement producing widening 
of the wrist. 



should be compared point for point. In the skiagraph the epiphyseal 
lines are distinct up to twenty years of age. 

A variety of fractures may occur in the lower end of the radius 
but by far the most frequent and most important is that produced 
by falls upon the outstretched palm. The direction of the force is 
such that the hand is shoved against the end of the radius, carrying 
it backward at the same time. As a result the lower end of the 
radius is driven into the shaft, shoved backward and rotated toward 
the ulna (Figs. 170, 171). 

Colles' fracture is one of the most easily recognized; producing 



COLLES FRACTURE 



243 



the characteristic hump— the silver fork deformity (Fig. 172). But 
it is by no means seldom that fracture occurs without deformity. 
In addition to the injury to the bone, the inter-articular fibrocartilage 
may be torn loose from both its attachments, the radio-ulnar liga- 




FiG. 172. — Colles' fracture. Silver fork deformity. (Moullin.) 

ments are strained or ruptured, and the head of the ulna carried 
forward. Sometimes the tendon sheaths are lacerated and blood 
extravasated into the synovial sac. 

Diagnosis. — -Determine the position of the styloid processes of the 




Fig. 173. — Reduction of Colles' fracture. Note grasp upon forearm and the lower 
fragment of the radius, traction and counter-traction being made; breaking up the 
impaction. (Scudder.) 



radius and ulna. If there is a fracture the styloid of the radius is 
pushed up to a level with that of the ulna, the wrist is broadened. 
The transverse lines on the flexor surface of the wrist are deepened 
and the axis of the limb bent toward the radial side. The pain is 



244 



FRACTURES OF THE EXTREMITIES 



pronounced, mobility and crepitus are absent. Pain is elicited by 
point pressure across the radius, an inch above the wrist. 

The X-ray is very useful in diagnosis of these fractures. 

Reduction is often difficult, but it is the chief thing and must be 
complete, otherwise the result will be a disappointment. Anesthesia 
is usually necessary. Clasp the patient's hand in your own, palm 
to palm, and with the other hand grasp the wrist at the site oi 




Fig. 174. — Plaster splint molded to maintain flexion and adduction, as shown in the two 



fracture. While the assistant makes counter-traction you make 
forcible traction on the hand, at the same time inclining it to the 
ulnar side and making -pressure upon the fragments. This combined 
traction, pressure and ulnar flexion may require force, but it will 
quickly reduce the fracture (Fig. 173). 

Another method' consists in having the assistant support the arm 
extended and supinated while you grasp the hand in such manner 
that your two thumbs may make strong pressure on the dorsum of 
the wrist. 

The fragments grate as the deformity recedes. 

Flexion and adduction are the capital points in this procedure and 
these positions must be maintained (Fig. 174). The best dressing is 
indicated in Fig. 175; or a roller plaster dressing may be applied, 
reviewing the position of the hand before the plaster hardens (Fig. 



COLLES FRACTURE 



245 



176). In some cases when the displacement has been slight simple 
anterior and posterior splints padded to suit the shape of the hand, 
may be employed. 

There is very little tendency to recurrence of the deformity if it is 
properly reduced, and the fixation is a secondary matter. If there 
was no deformity, or a very slight one easily reduced, it may be 

treated altogether by massage. 
Otherwise a week's fixation in one of 
the dressings just described is advisa- 
ble, to be followed by active massage. 





Fig. 175. — Pattern for plaster 
splint for Colles' fracture. 



Fig. 176. — Fracture of metacarpus. 



Andrews, of Mankato, Minn., emphasizes the necessity, in a 
reduction of this fracture, of a general anesthesia and a knowledge of 
the anatomy of the parts, which latter will be of more value to the 
tyro than any confusing description of the manner of taking hold of 
the parts. He remarks further that the head of the ulna must be 
brought back to rest in the sigmoid of the radius. 

Thinking the fracture set when merely the lower fragment of the 
radius is in position is a mistake that has brought sorrow to many 
a surgeon after union has taken place. 

The most frequent permanent deformity is the slumping forward of 
the ulna and the widening of the wrist. Andrews does not believe 
that early passive motion does a great deal of good and may do harm 



>r 

: 

» 

>rt 



246 FRACTURES OF THE EXTREMITIES 

by keeping the joint irritated by increasing the amount of callus and 
by causing useless suffering. Early massage, if gentle, is not only 
permissible, but to be recommended (Amer. Jour. Surg., July, 1909). 

FRACTURES OF CARPUS AND HAND 

Fractures of the bones of the carpus are not infrequent, and may 
occur with fractures at the lower end of the radius. The scaphoid 
is the most frequently involved, either alone or with one of the other 
bones. The injury results most frequently from a fall upon the han 
when it is extended and abducted. 

Fracture will be suspected from the pain and loss of function, an 
on examination the styloid process of the radius is found too close t 
the base of the first metacarpal, and the "tabatiere anatomique" 
the depression at the base of the thumb between the long and shor 
extensors of the thumb — is occupied by a hard body and pressure 
there is exceedingly painful. This sign alone is diagnostic of 
fracture of the scaphoid. Point pressure in case of fracture elicits 
much pain. Often the thenar eminence is ecchymosed. The exact 
character of the lesion can only be determined by the X-ray. Re- 
duction may be accomplished by putting the hand in the ulnar 
flexion and making pressure on the fragments through the palm. 
Excision may be necessary. 

Another type of injury consists of fracture of the scaphoid with 
dislocation of the semilunar. This is due to a fall upon the hand and 
is accompanied by pain, swelling and loss of flexion of the wrist, loss 
of extension of the fingers. The displaced semilunar may be felt 
in the palmar surface and the fossa at the base of the thumb is 
filled up. On the back of the wrist the os magnum may be felt. 

These cases untreated are likely to terminate in anchylosis of the 
wrist. 

The treatment consists in hyperextension of the wrist (under 
anesthesia) with the purpose of facilitating the pressure into its 
place of the semilunar. Subsequently the hand is flexed in flexion. 

In neglected cases it may be necessary to resect the semilunar in 
order to restore function. 

Fracture of the metacarpals is to be diagnosed by swelling, tender- 



FRACTURES OF THE FINGERS 



247 




Fig. 177. — Showing "sway-backed" appear- 
ance after fracture of the first phalanx of mid- 
dle finger. (Marsee.) 



ness, loss of function, and 
sometimes by crepitation and 
mobility (Fig. 176). 

The nature and degree of 
the displacement is variable 
and is often quite indetermina- 
ble without lateral and antero- 
posterior X-ray views. The 
deformity is to be overcome by 
traction on the corresponding 
finger confined with pressure. 
The palm is padded with cot- 
ton and firmly bandaged. 

About three weeks is required for repair. 

Fracture of the metacarpal 
of the thumb has some special 
characters and is designated as 
Bennett's fracture of stave of 
the thumb. 

It is probably the most com- 
mon and is the most important 
of the metacarpal fractures, 
difficult to reduce and hold. 

After reduction a plaster 
spica may be applied with the 
thumb abducted and subse- 
quently a window may be cut in the plaster over the base of the 
thumb and padding applied to press the fragments into place. In- 
stead of plaster three well- 
padded pencil splints may be 
used. 

Fracture of the fingers is 
sometimes compound, requir- 
ing a careful antisepsis. There 
is usually a tendency to dis- 
placement, so that after reduc- 

Fig. 179. — Mode of adjusting splint for simple 
tlOll Splinting IS necessary. fracture of the finger. {Marsee.) 




Fig. 178. — Splint with attachment for correc- 
tion of lateral deformity. {Marsee.) 




248 



FRACTURES OF THE EXTREMITIES 




Fig. 180. — Splint wrapped with gauze ad- 
justed for fracture of first phalanx, index 
finger. (Marsee.) 



A well-padded palmar splint is often all that is necessary, retain- 
ing it by bandages or adhesive 
strips. 

In many cases, however, the 
matter is not so simple and it 
cannot be denied that the 
splints ordinarily used are 
often very unsatisfactory, for 
they are not seldom so fash- 
ioned as to be inadequate to 
maintain extension, to immo- 
bilize perfectly, or to correct 
deformity. 
The first or proximal phalanx most frequently suffers and the 

fragments are likely to bulge 

toward the palm, giving the 

finger a " sway-backed " ap- 
pearance (Fig. 177). As Marsee 

has pointed out, this deformity 

will not yield to the ordinary 

splint, not indeed to any splint 

which is straight or but slightly 

curved. 

The appliance recommended 

for this condition and which may be useful in any fracture of th< 

digits consists of a strip of tin, zinc, copper, or galvanized iron 

14 inches long and 2% inches 
wide. This is to be folde< 
upon itself lengthwise and 
hammered flat so as to make 
a three-ply strip three-fourths 
of an inch in width. Of what- 
ever material made, it should 
be just flexible enough to be 
-bent readily by the unaide< 
fingers. Upon one end of th< 

strip, a piece of thin leather or canvas 4 or 5 inches long and 




Fig. 181. — Finger splint applied, 
aspect. (Marsee.) 



Dorsal 




Fig. 182 



•Splint applied. Palmar aspect. 
(Marsee.) 



FRACTURES OF THE FINGERS 



249 




Fig. 183. — Lateral angular deformity 
of middle finger.' Unsightly stump of 
index. (Marsee.) 



inches wide is to be riveted (Fig. 178) in order to give the strip 
stability when bandaged to the forearm. The strip is then shaped 
to suit the curved outline, in 
which position the fingers should 
be immobilized (Figs. 179, 180). 
The splint is to be adjusted 
snugly to the forearm, so that its 
end projects slightly beyond the 
tip of the finger, and fastened by 
strips of adhesive plaster, by a 
roller bandage, or by a light 
plaster-of-Paris casing. The fin- 
ger, carefully wrapped in several 
thicknesses of gauze, is then ad- 
justed with painstaking care to 
the splint in such a manner that 
the deformity, if any, is thoroughly 
overcome, and longitudinal and 
circular strips of adhesive plaster are applied (Figs. 181, 182). 
In this manner, almost complete control of the finger is assured. 

When, however, the lateral 
angular deformity is pro- 
nounced (Figs. 183, 184), some 
modification of the apparatus 
may be necessary. 

Two or three strips of zinc 
or copper are cut out 2M 
inches long and M inch in 
width. These are bent by one 
end around the splint, fitting 
it snugly but yet capable of 
being slipped backward and 
forward along the splint. The 
free end is left wide and is 
bent up to give the finger lateral support. This lateral support 
may be slipped along to the desired point and effectually cor- 
rects the deformity (Fig. 185). 




Fig. 184. — Crushed hand. Lateral angular 
deformity of little finger. (Marsee.) 



250 



FRACTURES OF THE EXTREMITIES 



Should two or more fingers be broken, several strips may be 
used side by side, but fastened to the same flange of leather oj 

canvas. For two fingers, 
splint of double width may be 
fashioned. 

Should the thumb b< 
broken, the splint may b< 
heated and bent laterally in 
proper shape, or an arm may 
be riveted to the ordinar 
strip. 

If the fracture or disloca- 
tion is compound, especially 
if attended with much dis- 
placement and difficulty in maintaining reduction, the fragment 
should be exposed and wired, for which one needs only a small 



1 ■ 19 

■ Mm 

HP 




.■■ f -V*^.i-. 



Fig. 185. — Splint applied to prevent lateral 
angularity. (Marsee.) 




Fig. 186. — Suturing bones of finger. 
Drilling. (Marsee.) 



Fig. 187. — Suturing bones of finger. 
Drawing suture through with crochet 
hook. (Marsee.) 



drill or awl, a fine steel crochet-hook and chromicized gut (Figs. 
186, 187). Such is the method taught by Marsee. 

The after-treatment is of importance. The splint will be re- 
quired probably for two weeks or longer, but in order to prevent 



: 



DIAGNOSIS OF FRACTURES OF THE THIGH 



251 



stiffness, passive motion should be begun at the end of the first 
week and repeated every other day at first. The fragments must be 
held in place during the first seances. Under this treatment, the 
stiffness and soreness will disappear together. 

FRACTURES OF THE LOWER EXTREMITY 



The first aid in these cases is of special importance, as has already 
been indicated. Even more than elsewherethe principle applies that 
there must be absolutely as little mo- 
tion as possible in order that the pa- 
tient may be spared pain and aug- 
mented shock; that the deformity may 
not be aggravated and the periosteum 
and other soft parts lacerated; and that 
a simple fracture may not be converted 
into a compound one with all the ad- 
ditional dangers of infection. The 
method of lifting a patient so injured 
has already been described. 

There are certain anatomical points 
useful in the diagnosis of injuries of 
the lower extremities, certain land- 
marks that must be kept clearly in 
mind; the anterior superior iliac spine, 
the spine of the pubes, the ischial 
tuberosity, the great trochanter, the 
patella and condyles of the femur, the 
tuberosities and crest of the tibia, the 
malleoli. 

There are three lines useful in men- 
suration: Remember that the line pass- 
ing from the anterior-superior spine to 
the ischial tuberosity overlies the apex 

of the great trochanter. This is Nelaton's line. Remember that 
the line dropped from the anterior-superior spine to the internal 
malleolus touches the inner border of the patella (Fig. 188). 




Fig. 188. — Measurement of 
lower extremity. Patient lying 
on the back looked at from above. 
Position of tape, hands, and limbs 
to be noted. (Scudder.) 



252 FRACTURES OF THE EXTREMITIES 

Remember that the line of the tibial crest prolonged reaches the 
second toe. 

A routine method should be practised in diagnosis. Inspection 
reveals changes in position, deformity swelling. Manipulation de- 
termines mobility, loss of function and pain; palpation discovers 
changed relations in bony landmarks and displacement of fragments; 
mensuration, shortening and deformity. In every case these details 
of examination should be carried out. Shortening is determined by 
two lines of measurement. 

If the injured limb is shorter than the sound, measuring from the 
anterior-superior spine to the internal malleolus, there is a fracture. 
Now if the distance from the top of the trochanter to the external 
malleoli are compared, shortening proves fracture of the anatomical 
neck. 

Fracture of the neck is indicated also by changes in the relation of 
the trochanter to Nelaton's line. 

FRACTURE OF THE UPPER END OF THE FEMUR 

Fractures of the upper end of the femur have been the subject of 
much discussion, and various forms of treatment have been recom- 
mended for imagined clinical and anatomical varieties. At the 
present time, nearly all surgeons are of the opinion that these le- 
sions may be grouped under two heads, impacted and non-impacted. 
Even this division is not important for diagnosis, but only for 
prognosis, since impaction, provided it is not broken up, offers the 
conditions most favorable for bony union (Fig. 189). 

Although the differential diagnosis is usually difficult, sometimes 
impossible, yet the presence of a fracture of some kind is usually 
determined after a little study. A severe contusion may indeed be 
mistaken for fracture, but this is not a serious error. On the other 
hand, it is a very serious error to mistake and treat a fracture about 
the hip as a contusion. In case of unresolvable doubt, treat the 
injury as a fracture. The diagnosis is made from several factors: 

(a) Pain is a symptom upon which one cannot greatly rely. It is 
more constant in impacted than non-impacted fracture because of 
the accompanying bruises of the soft parts. The pain is aggra- 
vated by pressure over the hip. Tenderness and especially a full- 



DIAGNOSIS OF FRACTURES OF THE THIGH 253 

ness in Scarpa's triangle is frequently observed. Pain with thick- 
ening of the trochanter means impaction. 

(b) Loss of function may also be due to contusion; moreover, the 
patient may be able to walk with an impacted fracture, so that this 




Fig. 189. — Impacted fracture at the hip. Note lines of fracture in head, neck and 

trochanter. 



j symptom is no certain criterion. However, the patient is usually 
unable even to draw his heel upward. 

(c) Eversion of the foot is nearly always present in some degree, 
but is more frequently indicative of non-impacted than impacted 
fracture, and is due to the weight of the limb. 



254 FRACTURES OF THE EXTREMITIES 

(d) Shortening is more frequently the accompaniment of im- 
pacted fracture. It is definitely determined by comparing with 
the sound side, measuring from the anterior-superior spine to 
the interna] condyle and internal malleolus; also by determining the 
relation of the trochanter to Nelaton's line (Fig. 188). 

(e) Crepitation is proof incontestable but rarely available. One 
should make no effort to elicit this symptom, fearing to break up 
impaction, which is an accident much to be deplored, according to 
the usually accepted view. 

Senn (Practical Surgery) says upon this point that it is better to 
be satisfied with the probable evidence of fracture. If the surgeon 
in his anxiety to obtain a perfect diagnosis moves the limb freely 
in all directions, he overcomes impaction, rupturing the cervical 
ligaments, demonstrating beyond all doubt the existence of the 
fracture and at the same time effectually destroying all hope of 
reunion. As Senn suggests, a useless limb is certainly a high price 
to pay for a perfect diagnosis. 

Age is an important feature in differential diagnosis. In the el- 
derly the injury is more likely to be intra-capsular with or with- 
out impaction: In the middle age extra-capsular, impacted frac- 
ture is the more likely; and in the child or adolescent, separation of 
the epiphysis is much the more frequent. 

Oftentimes the X-ray alone can determine the lines of fracture, 
and again it will often unexpectedly reveal a fracture in the young 
in whom contusion is the favored diagnosis. 

The treatment resolves itself into two lines of procedure, de- 
pending upon whether or not the fracture is impacted. In either 
case the treatment should be modified by the age and constitution of 
the patient. Confinement on the back may be fatal in the aged, 
and it is imperative in such cases to give the patient more freedom. 
This imperfect immobilization may eventually result in an imperfect 
union, but one must be consoled by the reflection that a fatal attack 
of hypostatic pneumonia may have been prevented. In the case 
of the aged, therefore, the main object is to get the patient on his feet 
as soon as possible. For the first week the limb should be fixed 
with sand-bags and massaged daily. After that a plaster spica ex- 



TREATMENT OF FRACTURES OF THE THIGH 



255 



tending halfway to the knee may be applied and the patient per- 
mitted to get about with crutches. 

In the case of undisturbed impaction in adults, the treatment is 
of the simplest form. The patient is placed on a smooth mattress, 
the limb supported by sand-bags or perhaps light extension applied, 
and systematic massage early instituted. Union may occur with 
no treatment at all. I recall the case of a man of sixty who fell in 
the street with what was supposed to be an apoplectic stroke. He 
was carried to his home to die but it was soon discovered that the 
conditions were not so serious but it was still supposed that he was 
paralyzed in one leg. After two months in bed he was able to get 
about with crutches but he had a very painful hip. A year later 
he was still on crutches and was brought to the hospital for examina- 
tion and the X-ray showed that he had suffered an impacted frac- 
ture of aggravated form. He had marked eversion and shortening 
but a firm union. Now a year later he still walks lame but without 
the aid of a cane. 

Union with deformity and large loss of function may be secured 
by doing little or nothing. 

Restoration of function implies restoration of form and this 
accomplished by breaking up the impaction, abducting the limb 
and fixing it with a plaster spica. 

Whitman has formulated a technic: Unless the condition of the 
patient forbids, he proceeds gently to break up the impaction 
under anesthesia. The limb is reduced by extension and gradual 
abduction to an angle of forty-five degrees, in the meantime sup- 
porting the upper end of the femur and rotating the leg inward. 

In this position, the limb is well covered with cotton batting, all 

.the bony points especially well protected and a flannel bandage 

'smoothly applied. A plaster spica is now applied extending from 

the lower ribs to, and including, the foot. The plaster fits the pelvis 

snugly and is molded close to the trochanter and posterior aspect 

of the joint. It is also molded to the patella and condyles, and to 

.the foot to prevent rotation. This dressing permits the patient. 

| to rise up in bed without much discomfort. 

The advantage of abduction is that it makes the capsule tense 
and thus aligns the displaced fragments; that it directs the surface 



256 



FRACTURES OF THE EXTREMITIES 



of the outer fragment toward that of the inner; that it relaxes the 
muscles that produce distortion by their traction; that it apposes 
the trochanter to the side of the pelvis and thus checks upward 
displacement. Repair in these fractures is slow and can hardly be 
completed within a year; thus prolonged after-treatment is nec- 
essary to restoration of function (J. A. M. A., Feb. 20, 1909). 




Fig. 190. — Non-impacted fracture of the anatomical neck of the femur; so called 

intracapsular fracture. 



If the case is one of non-imp action (Fig. 190) with much shortening 
and the condition of the patient will admit Senn advises reduction 
followed by prolonged immobilization in plaster extending from the 
waist to the toes and which is fenestrated over the trochanter for the 



TREATMENT OF FRACTURES OF THE THIGH 257 

purpose of applying lateral pressure. The lateral pressure he regards 
as essential to good union. But the plaster cast is difficult to apply. 
It is necessary that there be some sort of pelvis support and strong 
traction must be continued until the plaster is hard. 

The limb and trunk are encased in glazed cotton or what is much 
better drawers of stockinet. Three layers of plaster roller are 
run on from the thorax to the toes. The plaster splint is then 
molded to the outer side of the limb, pelvis, and trunk, and fresh 
layers of the roller applied. The plaster is molded very carefully 
to the bony points as by this means the dressing secures an effective 
grip. The plaster splint consists of ten or twelve layers of crino- 
line, cut in two sections, the first extends from the thorax down to 
the toes along the outer side and cut to a pattern which covers half 
the limb, the second section is wide enough to extend from the 
trochanter to the level of the ensiform and long enough to reach 
two-thirds about the body. It is fastened to the first section in 
the manner of a cross. 

FRACTURE OF THE SHAFT OF THE FEMUR 

In this fracture the lower fragment is nearly always displaced 
forward and backward. If the fracture has been produced by di- 
rect force, it may be transverse, but this is the exception. The 
diagnosis is simple: shortening, eversion, loss of function. 

Manipulation is unnecessary and decidedly to be avoided, not 
only that the patient may be spared the pain, but also that the 
trauma may not be aggravated, the periosteum torn, the muscles 
\ bruised, the vessels injured. 

Reduction. — This must not be begun till all the dressings are 
quite ready. General anesthesia. One assistant grasps the thigh 
y with both hands near the pelvis; the other assistant, the foot and 
lower third of the leg. As they make traction and counter-trac- 
tion the surgeon manipulates the fragments. The traction must 
be prolonged as these strong muscles relax only gradually. 

When the fracture is quite oblique and the pointed extremities 
j are caught in the soft parts, a little patience will be required to free 
the fragments. To effect this, slight rotation and oscillation must 
be added to extension and abduction. 
I X7 



258 FRACTURES OF THE EXTREMITIES 

How will one know that reduction is complete? 

(1) These points must exactly correspond when the two limbs are 
placed side by side: the upper border of the two patellae, the lowe 
border of the two internal malleoli, the two soles. 

(2) The limbs must be the same length, by measurement fro 
the anterior-superior ilica spine to the inner malleolus. 

(3) The line dropped from the iliac spine to the malleolus mus 
touch the inner border of the patellae. 

Dressing, — Many forms of splints are described; many of them 
complex; all effective in some degree. Whatever the form employed, 
the limb must be frequently measured and the patient's general con- 
dition kept under close watch. Scudder highly recommends a 
modified Buck's extension. Many are more successful with the 
plaster cast. 

Lejar recommends, as the simplest in emergency practice, the 
dressing of Tillaux. From a roll of adhesive plaster are cut eight or 
nine strips ij^ inches wide, and long enough to extend from the 
level of fracture down the side of the limb, over the sole of the 
foot after the manner of a stirrup, and up the opposite side of the 
leg to the level of the fracture. 

Begin by applying one of the strips in the direction indicated. 
Next slip a strip transversely under the thigh, another under the calf, 
and a third under the ankle, and make one circular turn of each. 
Next apply a second longitudinal strip slightly overlapping the first; 
follow with another turn of each circular strip, and so on. In this 
manner the strips are given a firm attachment. 

Every point of contact of the adhesive must be perfectly smooth. 
Every longitudinal strip must extend the same distance as its fellows 
below the sole in order that the extension weight shall make uniform 
traction on all the components of the stirrup. 

A cord is fastened to the stirrup, passed through a pulley at the 
foot of the bed and a weight of 5 or 10 pounds attached. If a 
pulley is not obtainable, a hole can be cut in the foot of the bed if it 
is wooden; or the cord may work over broom handle attached to an 
iron bedstead. The weight must be increased in the case of the 
muscular or in the case of a very oblique fracture. 

A case will illustrate the difficulties which may attend reduction in 



TREATMENT OF FRACTURES OF THE THIGH 



259 



these cases of fracture of middle of the shaft. A young man caught 
and crushed under a falling load of telegraph poles was brought to the 
City Hospital in full shock. It scarcely seemed possible for him to 
survive. It seemed certain that he must have had grave internal 
injuries though there was no direct evidence to that effect. The 
shock gradually subsided and no further evidence of visceral compli- 




FiG. 191. — Supracondylar fracture of the femur. 



cation arising, attention was directed to his fractured femur, which 
was broken about the middle. Efforts at reduction were painless 
but wholly ineffectual in securing a coaptation. Continuous exten- 
sion was applied but after two days an X-ray examination showed the 
fragments still separated and overlapping. 

Later an open operation found the broken ends interlocked with 
muscular tissue. With some effort they were freed, coapted and 
plated. Some suppuration delayed repair, but he finally recovered 
with a good limb. 



260 FRACTURES OF THE EXTREMITIES 

SUPRACONDYLAR FRACTURES 

These derive their importance from the frequency with which 
the fragments involve the knee-joint or the structures in the popliteal 
space, and from the difficulty of maintaining coaptation. Both 
these characteristics depend upon the obliquity of the fracture which 
usually extends from behind downward and forward (Fig. 191). 
The complications must be treated on general principles. 

The fixation may be any of the means just described for frac- 
tures of the shaft. In this case as in any very oblique fracture, 
flexion of knee and hip seem specially indicated. 




Fig. 192. — Hodgen splint for fractured thigh. (Moullin.) 

Hennequin's apparatus secures an efficient extension, combined 
with flexion of the hip and knee and permits the patient to sit up. 
Downey, of Gainesville, Ga., has thought out a device which involves 
the same principles as the Hennequin apparatus but is simpler in 
application. As Downey remarks (American Jour. Surg., March, 
1915) the dressing aims to secure at once the position of the Esmarch, 
Smith, Hodgen (Fig. 192), or Cabot apparatus; the extension of the 
Buck apparatus; the fixation of plaster of Paris. This is accom- 
plished by means of a double angular plaster-of-Paris splint. 



TREATMENT OF FRACTURES OF THE THIGH 26l 

The mode of application (briefly) is this: Secure counter- traction 
by a padded sheet passed between the legs and brought well up 
against the perineum; traction, by grasping the leg above the ankle 
with one hand, under the knee with the other. A plaster cast is 
applied from the toes to just above the knee, which is well flexed. 
Now secure coaptation. 

Next apply the second section of the cast, beginning at the upper 
border of the first and carrying the roller in the ordinary manner 
up to the ensif orm, all the while maintaining the traction with hip 
well flexed. Strengthen the outer side of the cast at the hip-joint 
by up-and-down folds of the roller or by metal splints. Split the 
splint if constriction is feared. 

AFTER-TREATMENT OF FRACTURE OF THE FEMUR 

Whatever the form of treatment, union will scarcely ever occur 
short of six or seven weeks. Whether union has occurred or not 
can be determined by manipulation of the fragments, and if they 
are well fixed the patient should be encouraged to use his crutches, 
but he should not be permitted to bear his weight on the injured leg 
short of three months. And even then only if he can lift his leg 
without pain, if the callus is rounded, and of moderate volume, and 
if pressure does not produce pain. 

Attention should be given the selection of the crutches which 
should just reach to the axilla and the cross piece for the hand should 
not be too low lest undue pressure fall on the musculo-spiral nerve. 
The edema, usually moderate, disappears with increased use and 
likewise the muscular atrophy. 

The knee, nearly always stiffened, gradually regains its move- 
ments. Shortening in some degree is inevitable but in a general way 
it may be said that in the course of time the functional cure is 
complete. 

FRACTURES OF THE FEMUR IN CHILDREN 

Fractures of the shaft present nothing special in the matter of 
diagnosis. 

The treatment of choice is the plaster spica much more easily 
applied than in the case of adults. It must be molded carefully and 



262 FRACTURES OF THE EXTREMITIES 

special precautions must, be taken to strengthen the cast in the 
region of the groin. 

The cast may be left off after a month. In the case of the new- 
born the best treatment is by vertical extension. In this portion the 
infant can be easily kept clean which is the most important part of 
the treatment. The fracture in the great majority of cases involves 
the upper third and requires much more force to effect a reduction 
than might be expected. 

The vertical extension is accomplished by applying adhesive plaster 
to both limbs in such manner as to make a small stirrup for either 
foot to which cords are attached and passed through pulleys and 
fastened to the cross bar over the bed. A weight sufficient to keep 
the legs straight in the vertical position is applied. 

A very light plaster roller incases the injured limb and which 
need not be changed till union is fairly firm which will usually be 
within two weeks (Fig. 193). 

Judet particularly recommends, in these cases, treatment in the 
horizontal position without extension, using for fixation a gutta- 
percha splint. The splint is cut out of a sheet of gutta-percha at 
least 6 mm. thick the upper part wide enough to encircle two-thirds 
of the trunk from the nates to the lower ribs. 

The lower portion is as long as the limb and so 
tapered as to cover two-thirds of the circumference 
of the entire limb forming in other words a posterior 
splint. 

This gutta-percha splint is next soaked in hot 
water and when soft is molded to fit the trunk and 
thigh and leg posteriorly, next dipped in cold water 
and when hardened is lined with absorbent cotton 
and, when the fracture is reduced, this splint is ap- 
plied and held on with a roller bandage. A splint 
ant's vertical ex- similarly molded to the anterior part of thigh may 
tension for frac- fo e added. This dressing may be removed every day 

ture of femur in . . , * . 

children. when the infant has his bath, taking care to support 

the limb in the interval. 
Separation of the epiphysis of the lower end of the femur is another 
injury which must not be forgotten (Fig. 194). 







SEPARATION OF THE EPIPHYSIS 



263 



A youth of sixteen was brought to the City Hospital for an ampu- 
tation of the thigh. He had a greatly swollen and painful knee, of 
long duration and upon which a great variety of treatment had been 
applied on various hypotheses. A careful manual and ! X-ray ex- 




Fig. 194. — Separation of epiphysis of lower end of femur; below is shown the 
epiphysis of the tibia in its normal relation. 



amination developed the presence of a bony mass projecting into 
the popliteal space from the inner side of the knee and the patella 
lay upon the outer aspect of the limb. 

The conditions manifestly insured a permanently useless limb. 



264 FRACTURES OF THE EXTREMITIES 

There was a history of a fall from a bicycle with injury to the knee, 
supposed to be a bruise. Nevertheless he had never born his weight 
on the limb from that time. 

A diagnosis of separation and displacement of the epiphysis 
was made and operation advised. A semilunar incision below 
the patella, followed by section of its tendon, exposed the joint and 
revealed the epiphysis united to the shaft in a distorted position. 
The spongy tissue was easily divided, the fibrous connections 
loosened, the ra^. surfaces of bone trimmed and the condylar end 
brought back into something like its normal position, and wired. 

The patella was with some difficulty shifted into its proper groove 
and the tendon reunited. The limb was fixed in plaster and after 
three weeks passive motion was begun. Now six months after the 
operation the outlines of the knee are practically normal, there is 
slight motion and the patient walks easily with only the help of a 
cane. 

Usually the condyles are displaced forward and laterally and the 
shaft projects toward the popliteal space. The change in the 
landmarks, the great swelling about the joint, the deviation in the 
axis of the limb is sufficient for a diagnosis. The treatment consists 
in replacement by strong traction with manipulation of the fragments 
under anesthesia, followed by fixation in plaster. 

Sometimes forced flexion as in the case of the elbow will succeed 
and after two weeks extension must be begun. 

Finally a few cases will resist reduction and will require immediate 
operation. 

FRACTURE OF THE PATELLA 

Fractures of the patella are comparable with those of the ole- 
cranon. They may be transverse, such are usually fractures result- 
ing from indirect force; or they may be vertical, or oblique, or 
multiple (Figs. 195, 196). 

There are two obstacles to osseous reunion: the action of the 
quadriceps extensor and the intervention of the patellar fascias, pre- 
venting exact coaptation. In spite of these unfavorable circum- 
stances, there is generally some form of fibrous reunion unless the 
fragments are very widely separated (Fig. 197). 






FRACTURES OF THE PATELLA 



265 



The treatment of the present time is by one of two methods — mas- 
sage or suture. If the fracture is transverse, with very little separa- 




Fig. 195. — Transverse frac- 
ture of patella. (Moullin.) 




Fig. 196.— Comminuted frac- 
ture of patella. (Moullin.) 



tion, and the conditions are not favorable for an aseptic operation, 
massage may be expected to give a good functional result. If the 
separation is considerable, massage r , _ , 

will still give a better result than 
any splints. 

In any case suturing is the ideal 
form, although the ideal cannot 
always be attained. Again, every 
compound fracture should be im- 
mediately sutured. J. H. Ford, 
whose experience with these frac- 
tures has been large, describes his 
method of procedure in ordinary 
fracture (Ind. Medical Jour., July, 
1907). 

In the non-operative cases he be- 
gins by elevating the limb for sev- 
eral days to relax the quadriceps. 
If there is effusion he bandages 
lightly with a flannel roller, or if 
the hemarthrosis is marked, a firm 
constriction is practised or ice-bags 
applied. 

As soon as the acute symptoms 
have subsided, which is after three to five days, massage is insti- 
tuted and daily applied. Begin with gentle constriction of the 




Fig. 197. — Fracture of the patella. 
Showing separation of fragments and dis- 
tension of the synovial sac. (Moullin.) 



266 



FRACTURES OF THE EXTREMITIES 



joint with the hands by an upward movement, and ending with 
more vigorous pressure of the sides of the patella and the joint. In 
the intervals the limb should be maintained on a posterior splint. 
After from four to six weeks of this treatment, he immobilizes the 
joint in a plaster cast, preferably for two weeks more, and subse- 
quently, he recommends a morning and evening massage and 
flannel bandaging until the functions are practically restored. 




Fig. 198. — Suture of patella. Method of drilling and passing sutures. (Labey.) 



The operative treatment is not simple, yet by no means beyond 
the skill of anyone who knows how to secure asepsis and to apply 
a bone suture. Begin with a semilunar incision, concave upward, 
well below the line of fracture and reaching to either border of the 
patella. Raise the cutaneous flap and expose the patella. The artic- 
ulation is carefully wiped out and freed of all fragments and clots. 



FRACTURES OF THE PATELLA 



267 



Fixing the upper fragment by appropriate forceps, two slight in- 
cisions are made in the periosteum at the points where the drill is 
expected to enter. Two tunnels are now drilled from above, emerg- 
ing on the face of the fracture well outside the line of the cartilage. 
The sutures are drawn through these openings and the process is 
repeated in the lower fragment, but great care must be used in se- 
curing a correspondence with the first two drill holes or the coapta- 
tion will be imperfect (Fig. 198). By traction on the sutures the frag- 
ments are brought together, and great care is necessary to avoid 




Fig. 199. — Suture of patella. Completing repair by suture of periosteum 
and fibrous coverings. (Labey.) 



including shreds of fascia. The sutures are tied, twisted firmly, and 
pressed down upon the bone. The periosteum and fibrous coverings 
are next sutured with catgut (Fig. 199). 

Ford prefers not to wire, but, after approximation, sutures the 
lateral fascia with No. 3 forty-day chromicized catgut and the 
; aponeurosis in front with No. 1. A No. 1 forty-day suture, 18 inches 
long, is then threaded on a strong, half-curved needle which is en- 
tered into the aponeurosis just above and on a line with the outer 

t 



268 



FRACTURES OF THE EXTREMITIES 



edge of the patella and follows the upper border of the patella to the I 
inner side where it emerges; is re-entered and carried down the inner 
side; again around the lower fragment, passing through the ligamen-, 
turn patella and emerging at its outer border. This retention suture 
is now tied tightly at this last point of emergence (Fig. 2co). The 
skin wound is next repaired without drainage. The limb is subse- 
quently immobilized for two~weeks when massage is to be begun. 




Fig. 200. — Fracture of patella. Circular suture. (Labey.) 



Ford lays down these rules respecting the treatment of simple 
transverse fracture : 

(i) Operative treatment should never be undertaken except under 
the best conditions for maintaining asepsis. 

(2) Even under aseptic conditions not every case should be oper- 
ated on, but only those in which the separation is at least H 
inch and the " reserve extension apparatus" is compromised by 
lateral tears. 

(3) Operative treatment fulfills all the indications in a degree 
which the non-operative treatment can only partially achieve. 

(4) Early massage favors complete restoration of function and 
should be used in all cases. 



FRACTURES OF TIBIA AND FIBULA 



269 



(5) In operative treatment open arthrotomy should be practised. 

(6) Absorbable suture material applied only to the soft parts is 
- sufficient in nearly every case. 

FRACTURES OF THE LEG 

Fractures of the leg present many variations, but the prognosis 
and the difficulties of treatment depend chiefly upon whether the 
fracture is transverse or oblique. If transverse there is usually 



. 




Fig. 201. — Longitudinal fracture of tibia and oblique fracture of fibula. 

slight displacement, easily reduced and easily maintained; if oblique 
there may be much displacement which is difficult to reduce and hold, 
;and often results in much loss of function. 

Transverse fractures more commonly are due to direct force and 
the lesion corresponds to the application of force. Oblique fractures 



* 



270 



FRACTURES OF THE EXTREMITIES 



are more commonly due to indirect force and the two bones give way 
at their point of least resistance, which in the case of the tibia is at 
the junction of the middle and lower third; in the case of the fibula 
in the upper third. In general, displacement is always favored if 
both bones are fractured (Fig. 201). 

The diagnosis of these injuries usually offers but little difficulty. 
The deformity, loss of function, pain and crepitus, and preternatural 




Fig. 202. — Fracture of upper end of tibia, involving the joint. 



mobility leave but little doubt except when the injury is at the upper 
end, and where the joint may be involved (Fig. 202), or when the 
fibula alone is fractured. A useful test for fracture of the fibula is 
compression of the two bones some distance from the suspected 
site; the pain occurs not at the point of pressure but at the point 
of fracture. 

If there is great displacement of the fragments the deformity is 
pronounced, the foot turns to the outside, the fragments may be 



FRACTURES OF THE TIBIA 



271 



felt projecting under the skin which soon becomes greatly discolored 
and often covered with blebs. 

Reduction.— The assistant grasps the leg at the knee, the surgeon 
grasps the foot with one hand and the heel with the other; or two 
assistants may make the necessary traction while the surgeon man- 
ipulates the fragments. 

What is the test of good coaptation? The crest of the tibia forms 
a continuous line without projections or 
depressions. This line prolonged strikes 
the first metacarpal space. The internal 
surface of the tibia is smooth and uniform. 
With the foot at a right angle, a line 
dropped from the anterior-superior iliac 
spine to the inner border of the great toe 
touches the inner border of the patella. 




Fig. 203. — Cloth cut to fit the limb and notched at the ankle in order to be more easily 
adjusted to the malleoli when it is soaked with plaster. (Lejars.) 

The reduction is by no means so simple as it seems and even when 
• easily accomplished may be difficult to maintain while the dressing 
^is applied. A maneuver which often succeeds without the use of 
; great force is that which is practiced in the open operation. The 
'limb is flexed at the line of fracture and the two fragments brought 
into contact along the line of their lower borders. This affords a 
(leverage when traction is applied. Coincident with traction the 
limb gradually straightens and the lower fragment adapts itself to 
the upper. 

1 



272 



FRACTURES OF THE EXTREMITIES 



Dressing. — This will vary somewhat, depending upon the situation 
and tendency to displacement. In the simple case of fracture of the 
shaft of the tibia, following the counsel of Stimson, it is best to put 
the patient to bed with the limb in a Volkmann splint for about a 
week until the swelling has subsided, and then to encase it in plaster 
of Paris. Immediate application of the plaster of Paris is objec- 
tionable because it cannot be determined from the first whether the 




Fig. 204. — Plaster splint applied and fixed with roller plaster bandage, 
supporting limb and applying roller. (Lejars.) 



Note manner of 



swelling will increase or diminish. The two dressings may be com- 
bined by applying a plaster splint from the first, and this we prefer. 
Lejars describes the construction of such a splint. He measures 
from the middle of the thigh down to the heel and up the sole to the 
toes, and this will be the length of the sixteen layers of crinoline from 
which the splint is to be made. Take the circumference of the thigh, 
the knee, the middle of the leg, the ankle, and transfer the measures 
to the crinoline which was cut wide enough in the first place to en- 






FRACTURES OF THE TIBIA 



273 



circle the thigh. Connect the ends of these cross measurements with 
a chalk line and in this manner one forms a rough outline of the limb, 
and the bandage is cut accordingly. Some prefer to apply the mate- 
rial to the sound limb and mark it off in that way. 

Opposite the ankle a notch 
should be cut in the dressing, 
running toward the heel, that 
the dressing may be more 
readily fitted (Fig. 203). This 
is soaked with liquid plaster 
and applied while the extension 
and counterextension are main- 
tained and the foot fixed at a 
right angle. This tension must 
not be relaxed until the plaster 
has hardened. The dressing is 
completed by applying a roller 
bandage (Fig. 204). 

While the plaster is harden- 
ing it is necessary to test the 
reduction by the measurements 
indicated and to readjust the 
alignment, the assistant must 
be warned not to carry the foot 
forward in making traction lest 
angulation occur. 

I The plaster must be well 

' molded about the knee and the 
ankle in order that shortening 
may not recur. 

Oblique fractures (Fig. 205), hard to hold, are likely to be near 

( the lower end. The quadriceps extensor pulls the upper fragment 
forward, and the gastrocnemius pulls the lower fragment backward. 
The special form of dressing which Scudder recommends for this 
form of fracture is made by a combination of plaster and adhesive 
strips. The adhesive strips are applied as indicated (Fig. 206). A 
thick roll of sheet wadding is applied to the sole of the foot, and a 
18 




Fig 20; 



-Typical oblique fracture of the 
shaft of tibia. 



274 



FRACTURES OF THE EXTREMITIES 



J 



Ik- 



IB 






plaster bandage applied from the toes to above the knee. A buckle 
looking upward is incorporated in the plaster just above the level of 
the knee. A slit is left in each side at the ankle for the lower exten- 
sion strips to come through. 
When the plaster has hardened, 
the upper extension strips are 
fastened in the buckles and the 
lower extension strips pulled out 
through the slits and drawn tight 
around the foot piece after the 
wadding at the sole has been re- 
moved. The purpose of this 
arrangement is to maintain ex- 
tension. 

Whatever form of dressing is 
used the limb must be watched 
to see that no displacement oc- 
curs. While a simple fracture 
usually firmly unites within six 
weeks, those which have been hard 
to keep reduced will remain weak 
much longer. As soon as there is 
sufficient union to prevent dis- 
placement, then massage should 
be begun and continued till the 
limb's functions are restored. 

Whether it is safe to leave off 
the dressing is to be determined 
largely by the character of the 
callus which should be fusiform 
and of moderate volume. The 
pain on pressure and movement 
must be slight and of course there 
must be no mobility of the fragments. 

Crutches must be used to begin with and light, easily removable 
splints must be worn. 

Marked swelling may always be expected as soon as the patient 



CL 



b 



Fig. 206. — Plaster traction splint; a 1 
Application of adhesive-plaster extension 
strips; b, plaster bandage allowing exit of 
extension straps. Note space left below 
the sole to allow for effective traction and 
buckles to which the upper extension is 
attached. {Scudder.) 



FRACTURES OF THE TIBIA 



275 



begins to get about on crutches, a condition which may alarm him 
greatly but this and the pain will gradually subside with increasing 
muscular and articular activity. 




Fig. 207. — Perfect coaptation secured by plating, but in this case same results would 
probably have followed non-operative treatment since the fracture was not oblique. If 
the fracture requires plating at all a longer and stronger plate than is shown should be used. 



The muscular atrophy and joint stiffness are not the least to be 

considered of the complications of convalesence and it is to be 

remembered they are aggravated by prolonged immobilization.* 

*For remarks on plating see Fig. 207; fracture of the anterior tuberosity of 
the tibia, Fig. 208; and page 207. 



276 



FRACTURES OF THE EXTREMITIES 



Pott's Fracture. — Fracture of the fibula with eversion and ab- 
duction of the ankle has a character of its own. As Stimson remarks, 
the diagnosis can usually be made at a glance (Fig. 210). Three 
points of tenderness on pressure are constant and characteristic: one 




Fig. 208. — Fracture of the tubercle or anterior tuberosity of the tibia, point of insertion 
of the patellar tendon is not rare and usually due to striking the knee while strongly flexed. 

There may be considerable displacement and disability and in some cases it may be 
necessary to wire the fragment. Usually fixation of the extended leg for three weeks is 
sufficient for a union. 



in the groove between the tibia and external malleolus; another at 
the base of the internal malleolus; the third over the outer aspect of 
the fibula, marking the point of fracture. Marked ecchymosis 
appears beneath the external malleolus and sometimes beneath the 
internal (Fig. 211). Immediate reduction should be the rule. 



FRACTURE OF THE FIBULA 277 

. Reduction. — Grasp the foot in one hand, the heel in the other, and 
while the leg is steadied by the assistant, draw the foot forward and 




Fig. 209. — Fracture of the fibula in its lower third or near the malleolus may be unsus- 
pected and the symptoms be attributed to a sprain of the ankle. But swelling and tenderness 
above the ankle with much pain on walking will give rise to the suspicion of fracture 
which the X-ray will confirm. 

The patient must keep off his feet for three weeks with the leg lightly splinted with the 
foot in good position, massage. The nearer the fracture is to the joint the greater the 
tendency to flat foot. 

inward. If this does not entirely succeed, the fragments may be 
pressed into place. With the foot at a right angle and the malleoli 
in their normal relations, the dressing is applied. This dress- 



278 



FRACTURES OF THE EXTREMITIES 




Fig. 210. — Pott's fracture. 



ing, to quote Stimson further, is preferably a posterior and lateral 

plaster splint although the 
plaster cast may be used. 

The plaster splint may be 
made from twelve to thir- 
teen layers, cut from a 
4-inch plaster roller. The 
posterior splint should be 
long enough to extend from 
the toes along the sole and 
up the calf nearly to the 
knee (Fig. 212). The lateral 
one should begin just in 
front of the external malle- 
olus, pass over the dorsum of the foot to the inner side, under the 

whole and up along the outer side of 

the leg to the same height as the poste- 
rior (Fig. 213). They are snugly molded 

and bound to the limb while still wet, 

with a roller bandage. 

In the meantime, till the plaster sets, 

the reduction must be maintained. 
Dupuytren's splint is often of great 

service in this fracture, especially as a 

temporary dressing. It consists of in- 
ternal lateral splint, well padded over 

the ankle and which extends from 

above the knee and projects beyond 

the foot. It is held in place by a 

bandage at the knee and above the 

ankle. The foot is then abducted, flexed 

to a right angle to the leg and secured 

to the splint by a third bandage (Fig. 
214). 
These fractures are always serious 

from a functional point of view and the 

after treatment is of the utmost importance. 




Fig. 211. — Pott's fracture. Note 
fracture of internal malleolus. 



POTT S FRACTURE 



279 





Fig. 212. — Posterior splint applied. 
(Stimson.) 



Fig. 213. — Lateral splint 
[ applied. (Stimson.) 




Fig. 214. — Dupuytren's splint. Temporary dressing for Pott's fracture. 



2 SO 



FRACTURES OF THE EXTREMITIES 



Flat foot is likely to occur from too early use not less than from 
imperfect reduction. 

Six to twelve weeks is required for a repair sufficient to bear the 

patient's weight. 

- 

FRACTURE OF THE FOOT 

Fracture of the astragalus may occur independent of injury to 
the other bones and may occur with or without displacement of 




Fig. 215. — Fracture of os calcis; result of fall, landing upon the feet. 

the fragments. The swelling of the ankle, the pain on pressure 
on the heel suggest the nature of the injury but only the X-ray 
can make a definite diagnosis. Fracture of the body usually calls 



FRACTURES OF THE FOOT 281 

for enucleation because of the non-union which is the usual event 
and is accompanied by a persistent but low grade of arthritis. 
Fracture of the neck is more favorable under proper treatment 
which consists in prolonged immobilization in forced extension. Six 
weeks at least must elapse before any w r eight is borne. It is essential 
that this condition be not mistaken for a sprain. 

Fracture with displacement may give rise to various deformities 
but the most common is lateral dislocation of the foot. Its inner 




Fig. 216. — Fracture of phalanges of the foot. 

border is markedly curved, the outer malleolus projecting and the 
dislocated fragment palpated in front or behind the joint. Under 
such circumstances an open operation is indicated with the purpose 
of replacing the fragments or performing a partial or complete 
astragalectomy, and in this latter the operation will usually terminate. 
Fracture of the os calcis, due to falls, the patient landing on his 
feet, produces an impaction which flattens and widens the heel 
and lowers the malleoli. The pain, swelling and disability are con- 



282 FRACTURES OF THE EXTREMITIES 

slant but an accurate diagnosis can be made only by the X-ray 
(Fig 215). 

The prognosis depends in some degree upon the line of fracture, 
but on the whole the outlook is bad. 

Prolonged rest, massage, hot baths, etc., may eventually overcome 
a large part of the lameness but under certain circumstances an 
operation with readjustment and suture of the fragments will produce 
an excellent result. . 

Fractures of the bones of the toes require much longer immobiliza- 
tion than corresponding fractures in the hand (Fig. 216). The de- 
formity and callus formation may produce points of pressure that 
become serious impediments. These fractures should therefore be 
treated with circumspection. 



CHAPTER XV 
COMPOUND FRACTURES 



It were perhaps better at once to proscribe the ancient term "Com- 
pound' ' as applied to open fractures; but after all it conveys an idea 
of duplication of traumatisms. And it is only within a recent period 
that a compound fracture did not mean also an infected one. 

Thanks to antisepsis, most open fractures at this time, progress 
toward repair as rapidly as the closed. 

But these open fractures require a particular care, and without 
appropriate treatment, are as prone to give rise to dangerous compli- 
cations as in former times. The outcome in a given case depends 
largely on the first treatment. The indications are various, deter- 
mined by the amount of fragmentation, the degree of destruction of 
the soft parts, the injury to the blood vessels and, based upon these 
factors, several clinical groups may be distinguished. 

I. Compound Fracture, Small Skin Wound; no Injury to Blood 
Vessels. — The first point to be determined is whether the skin lesion 
communicates with the bone lesion. Often a fragment of bone pro- 
jects; in other cases an undue amount of bleeding suggests perforation 
of the soft parts. In any event, the wound must not be probed and if 

| there is doubt the fracture must be regarded as open. The treat- 
ment is simple and exact. Cover the wound and proceed to paint the 
field with iodine. Wait five to ten minutes for the solution to pene- 
trate the skin and then proceed to sterilize the wound itself, injecting 
it with iodine from a medicine dropper and subsequently, if the size 
of the opening permits, wipe it out with a gauze swab saturated with 
iodine. A sterile dressing is applied and from this point the fracture 

' is treated as if it were closed, and appropriate splinting employed. 

II. The Wound is Large, the Bone Exposed and Soiled. — In this 
1 case, under general anesthesia, the wound must be freely enlarged 

and the ends of the bone, as well as the soft parts, painted with 
iodine. If every angle and corner of the wound and the bone is 

t 2Z3 



284 COMPOUND FRACTURES 

particularly and carefully cleaned with the solution, infection is 
only remotely probably. The bones are to be adjusted, fixed with a 
bone clamp if the apposition is difficult to maintain, the muscle and 
fascia sutured without drainage, and the skin wound with drainage. 
Some form of splint is applied which will readily permit inspection 
of the wound, and the bone clamps removed. The dressing must be 
ample. 

III. Large Wound, much Crushing of the Soft Parts, much Frag- 
mentation. — The principle of antisepsis is the same as in the 
previous case, but the disposition of the fragments presents a new 
problem. It is best, we think, to proceed in this wise: Sterilize 
the skin and other soft parts with iodine, enlarge the wound, ster- 
ilize the bone fragments with the iodine and then douche the cavity 
with hot normal solution until all the clots and debris are removed 
and all the oozing checked. Next proceed to restore the outline of 
the bone, replacing the fragments as nearly as possible in their nor- 
mal relations, suturing them to the main body of bone with chromic 
gut or securing them by bands of the same material, encircling the 
shaft. 

These cases are better drained for the first two or three days after 
which, if there are no signs of infection, the drain should be left off. 

Formerly, it was the practice to discard the fragments of bone. If 
infection can be avoided or reduced to a minimum the fragments 
will live and add greatly in restoring form and function. Even if the 
periosteum is denuded, the fragments, though destined to be ab- 
sorbed, will serve as scaffolding for the new bone cells, greatly 
promoting osteogenesis. 

IV. Extensive Fragmentation, Extensive Destruction of the Soft 
Parts, Obliteration of the Principal Arteries. — In such cases it is the 
part of wisdom to amputate. Occasionally the limb may be saved 
but the attempt exposes to an infection that may cost the patient 
his life. The recovery of a useful limb in these circumstances is 
so rare as scarcely to justify assuming the septic risk. 

V. Infected Compound Fracture. — If infection occurs by reason of 
no treatment, or unsuccessful treatment, the temperature rises, 
the limb swells, the pain augments — in short, the local and consti- 
tutional signs and symptoms of infection supervene. These must be 



GAS BACILLUS INFECTION 285 

watched for in every case, and the patient kept under close sur- 
veillance. 

Once infection manifests itself, the wound must be opened, re- 
moving the sutures if necessary, and the wound irrigated with per- 
oxide of hydrogen. Oftentimes it is only the skin wound which is 
infected and the deeper levels of the wound should not be disturbed 
until it is certain they have been invaded. 

Even if the bone itself is involved an excellent result may still be 
obtained, provided the splinting is efficient, the drainage ample, and 
the general treatment sensible. 

So much cannot be said if the infection is from the gas bacillus. 
This extremely dangerous form of sepsis develops usually the 
second or third day and is preceded by pain in the wound, out of all 
proportion to its apparent seriousness. The wound looks red and 
; angry and exudes a bloody, fetid serum; presently the limb begins to 
swell, the skin is crepitant, and blebs form. These manifestations 
extend with the greatest rapidity, accompanied by grave constitu- 
tional manifestations which end in death in twenty-four to seventy- 
two hours. The diagnosis must be made at the very beginning of 
1 the process if the treatment is to be of any use. Severe pain, an 
unexpected rise in temperature the first days should put one on his 
guard and at the first appearance of crepitation in the skin an am- 
putation well above the infected site must be performed. If the 
case is untreated or if the treatment is ineffective the progress of 
the disease is extremely rapid although there is nothing else charac- 
teristic of this form of toxemia. 

A workman was brought to the City Hospital with a compound 

.fracture of the lower end of the radius. The injury was twenty-four 

i hours old. The wound was cleansed, the fracture splinted; but the 

patient suffered extremely, out of all proportion to his injury; his 

temperature began to rise and at the end of the second day it was 

(dear that a gas bacillus infection was under way. He understood 

! no English, but an interpreter explained that he must loose his arm or 

his life. He chose the latter. At the end of the third day the arm 

and shoulder were immensely swollen, the skin crepitant and cov- 

1! ered with blebs and a few hours later he died in great agony. 

An almost identical injury occurred in a fall from a cherry tree. 



2S6 



COMPOUND FRACTURES 



The signs of the infection promptly developed, the end of the bone 
having been covered with soiL The patient, a middle aged woman, 
consented readily to amputation at the shoulder. The flaps were 
left open and packed with gauze saturated with peroxide. She made 
an uninterrupted recovery. 

In the young and healthy patient in the very early stages of the 
disease a more conservative treatment may succeed. Multiple deep 
incisions, packing the wounds with peroxide gauze or injecting the 




Fig. 217. — Compound fracture of tibia. (Moullin.) 

soft parts above the level of infection with the peroxide. Finally the 
danger of tetanus is to be emphasized and in every case of compound 
fracture which has not been treated from the first in the manner 
described, a prophylactic dose of anti tetanic serum should be 
administered. 






COMPOUND FRACTURE OF THE TIBIA 

These are by far the most frequent and require a special attention 
both that infection may be avoided and that the limb's functions may 
be preserved. (Fig. 217, 218) The tibia is so near the surface and 
the line of fracture is so likely to be oblique, producing sharp points 
of bone, and displacement is so common; these facts explain the 
frequency of open fractures of the tibia. 

The antisepsis in these cases presents no special feature; the chief 
problem is in maintaining coaptation. If the fracture is oblique or 
the bone much splintered, it is best to proceed in this manner; after 
cleansing both outside and inside the wound with iodine, enlarge 



COMPOUND FRACTURE OF THE TIBIA 



287 



the wound freely, clean out all the clots and debris. The amount of 
injury to the soft parts is often surprising. Expose the bone suf- 
ficiently to secure an accurate coaptation of all the fragments. Now 
apply a bone clamp in order to force the bones into intimate contact 
and to hold them in that position until the dressing is applied. 

Before beginning the operation, have fifteen layers of crinoline cut 
from a pattern for a posterior splint and saturated with dry plaster of 




Fig. 218. — Compound comminuted fracture of tibia and fibula. 



Paris. The dressing having been applied to the wound in such manner 
as not to interfere with the removal of the clamp, the posterior splint 
is soaked and then molded to the leg and fixed with a few layers of 
roller plaster. In the course of fifteen minutes the plaster is hard- 
ened and the clamp may be loosened and removed. Interrupted 
sutures placed but not tied can now be tightened and an additional 
cover of gauze applied to the wound. 



288 COMPOUND FRACTURES 

Usually there is considerable oozing for the first few hours, necessi- 
tating frequent change of dressings, the best form of which is gauze 
saturated with alcohol, this covered with absorbent cotton and the 
whole firmly bandaged. With a properly applied and effective splint 
the limb can be handled and the dressings changed with but little 
difficulty. Special care must be taken to prevent soiling of the 
plaster splint since changing this short of two weeks may result in 
recurrence of some displacement. Mild infection may occur but is 
easily managed on general principles. Our results by this method 
have been excellent. 

COMPOUND FRACTURE ABOUT THE ANKLE AND FOOT 

Fractures of this variety are frequent; always serious; and the 
prognosis more or less uncertain, depending upon the degree of in- 
fection and destruction of the soft parts. 

Suppose a fracture of the inner malleolus : the soft parts are widely 
separated, the joint cavity exposed, the astragalus dislocated. Such 
an injury must be as conservatively treated as an abdominal wound. 
Under no circumstances must the wound be explored with unclean 
fingers or without careful cleansing of the field. Only after all the 
preparations for definite treatment are made is the wound to be ex- 
amined. If transportation is necessary, a temporary splint is pro- 
vided, but at least do not cover the wound with a dirty handkerchief. 
If there is much hemorrhage, circular constriction of the leg about 
the knee will temporarily suffice. 

The first dressing will determine the future of the limb, perhaps 
even the life or death of the wounded. The whole foot and the lower 
half of the leg are most carefully disinfected and the fracture and 
joint cavity swabbed with iodine, enlarging the wound if necessary 
to expose every nook and corner in order to wipe out foreign bodies, 
splinters of bone and clots of blood. In this case, merely chosen for 
example, the destruction of tissue is usually slight. After the 
cleansing, replace the parts, leave one or two drains in the partly 
sutured wound, bandage amply and place the limb at rest. 

The situation is less simple where there is much destruction of 
tissue, as in the case where the ankle is crushed. 



COMPOUND FRACTURE OF ANKLE 289 

Begin with hot irrigations of normal salt solution. Do not fear to 
enlarge the wound freely. It is of great importance that one be able 
to determine definitely the conditions in the wound and to see what 
he is doing. 

You may find large fragments deformed and overlapping. Try 
to replace them and often you will be thus enabled to restore the 
contour of the joint. To retain these fragments, wiring or nailing 
the fragments will often be an almost indispensable aid. 

Another case: The epiphyses are reduced to fragments of various 
sizes and forms. In irrigating, they flow away with the solution, so 
loosened are they. The rest hang by a mere shred. 

Reposition is here useless. The wreck is too great. You must 
proceed to do an atypical resection. Do your best to spare the mal- 
leoli or at least two processes which will serve to prevent lateral dis- 
location when the joint is healed. 

After this operation insert two drainage-tubes, one on either side; 
and if there is considerable oozing, add an aseptic tamponade. 

The prognosis is worse if infection has developed and there is fever, 
redness, and swelling in the limb. Amputation will be the measure 
of last resort and yet do not amputate until free opening has again 
been tried. Irrigate with peroxide. The removal of dead bone, 
etc., is followed by deep drainage but this must be done without 
delay. It is not union, or consolidation, or function of the limb 
which is the chief concern. It is infection against which all the forces 
of antisepsis are marshalled. 

Osteomyelitis is the contingency feared. In such a case, do not 
employ a typical amputation or resection, but an atypical one, re- 
moving only such tissues as must be removed, and later when the in- 
fection has disappeared, the necessary operations may be done. For 
additional remarks on treatment of compound fractures see Gunshot 
Fractures (page 155). 



19 



CHAPTER XVI 

FRACTURE OF THE CLAVICLE, SCAPULA, RIBS, 

SPINE, PELVIS 

Fractures of the clavicle formerly occurred more frequently than 
any other, but are not now so frequent. One-half of the cases are 
in children. The break very much more often occurs in the middle 
third, occasionally in the outer third, but rarely in the inner third. 
In the middle third, the inner fragment overrides the outer, the re- 





FiG. 219. — Fracture of clavicle. Inner fragment Fig. 220. — Velpeau's bandage for 
lifted upward by sterno-mastoid. (Moullin.) fractured clavicle. (Stewart.) 



suit of the action of the sterno-cleido-mastoid and the muscles that 
pass from the thorax to the humerus, and the weight of the shoulder 
(Fig. 219). 

The patient leans his head toward the injured side and supports 
the elbow, the position of greatest comfort. The nature of the 
accident, the pain, deformity, crepitus, and mobility determine the 
diagnosis. 

Reduction. — Seat the patient on a low stool; direct the assistant 
to stand behind and to grasp the patient's shoulders, steadying the 
sound one with one hand and lifting the injured one upward, back- 

290 



FRACTURE OF THE CLAVICLE 



29I 



ward, and outward. At the same time the operator stands in front, 
helping move the shoulder; and, by pressure and manipulation of 
the clavicle between finger and thumb, molds the broken ends into 
place, 

The reduction is complete when the injured shoulder is as long 
as the sound one, measuring each from the sterno-clavicular joint 
to the tip of the acromion, landmarks which can always be defined. 
Feel along the injured clavicle for any irregularities. Apply the 
dressing. (1) If the patient is to be kept in bed for other reasons 




Fig. 221, — Sayre's dressing. Fig. 222. — Sayre's dressing corn- 
First stage. {Moullin.) pleted. Posterior view. (Moullin.) 



Fig. 223. — Anterior 
view. {Moullin.) 



than the clavicular fracture, it will be sufficient to keep him on his 
back wdth a small pillow between his shoulders and with the hand 
lifted to the chest. 

(2) Any bandage or dressing which draws the shoulder upward, 
outward, and backward, and holds it in that position will serve. Of 
the dressings, a number are especially recommended, among them, 
the Velpeau type of bandage (Fig. 220). They need to be applied 
for three or four weeks. 

In ordinary practice, the Sayre's dressing is excellent. The es- 
sentials are two adhesive strips 3 inches wide and long enough 
to go once and a half about the body, absorbent cotton, roller band- 



292 



FRACTURES OF THE CLAVICLE, SCAPULA, RIBS, ETC. 



ages. Beginiby fixing the end of one adhesive strip loosely about the 
injured arm iust below the armpit. The loose end carried around 
the^body will pass over the lower ends of the scapulae. Before com- 
pleting the turn about the body, place layers of cotton wherever the 
cutaneous surfaces are to be in contact. The turn of the adhesive 
strip about the body is completed. This holds the shoulder in the 
backward and outward position (Fig. 224). The hand is drawn 
across the chest toward the sound shoulder and the second adhesive 




Fig. 224. — Mayor's sling. First stage. (Lejars.) 

strip is applied. Fix one end over the sound shoulder and pass it 
across the back to the elbow (Fig. 222). It covers the point of the 
elbow and follows the arm across the chest to the starting-point 
(Fig. 223). It is designed to lift the shoulder upward. A few turns 
of roller bandage around the chest lend additional support and com- 
plete the dressing. 

Romer describes a method of dressing with adhesive strips which 
does not require the arm to be fixed to the side (Lancet, London, 



THE MAYOR SLING 



293 



March 31, 1909). Three strips of Z. O. plaster, each an inch and 
a half in width, should be applied from a point immediately above 
the nipple, passing over the clavicle to a point below the angle of the 
scapula. The middle strip should cover the site of the fracture and 
should be first applied, the lateral ones overlapping it. The strips 
should be firmly applied while the fragments are kept in apposition. 





Fig. 225. — Mayor's sling. Second stage. 
The bandage is molded snugly to the arm. 
(Lejars.) 



Fig. 226. — Mayor's sling completed. 
(Lejars.) 



The scapula may be steadied by a strip crossing its lower angle lat- 
erally. The arm is to be carried in a sling. 

Mayor's sling serves an excellent purpose here as well as in certain 
injuries to the arm. It is applied in this manner: 

Take a square of strong, unbleached muslin, or similar material, 
large enough to reach easily about the body; fold it into a triangle. 



294 



FRACTURES OF THE CLAVICLE, SCAPULA, RIBS, ETC. 



The elbow having been flexed to an acute angle and the hand carried 
toward the sound shoulder, the bandage is carried across the flexed 
arm and around the chest, its upper level being just below the level 
of the axilla (Fig. 224). The two points are fastened behind with 
a safety-pin or tied. 

Now turn the third point of the triangle upward between the 
flexed arm and the body, and carry it up over the shoulder of the 
injured side (Fig. 225). Mold the bandage well, so that it fits and 
supports the forearm snugly. The dressing is completed by bands 
crossing over the shoulders and connecting the anterior and posterior 
parts of the bandage after the manner of suspenders (Fig. 226). 

FRACTURE OF THE SCAPULA 



These fractures are comparatively rare, about 1 per cent, of all 
fractures. 

The body, the spine, the acromion process, the coracoid process 

may be involved and the fracture 
is usually due to direct violence. 

The X-ray will often be neces- 
sary to locate the lesion definitely 
although the pain, tenderness, and 
perhaps crepitation will determine 
the presence of some kind of frac- 
ture. In the case of the acromion 
process the functions of the deltoid 
are disturbed; in the case of the 
coracoid, the biceps and pectoralis 
minor. Respiration may be pain- 
ful by reason of the pull on the 
latter muscle. 

The action of these muscle 
must be considered also in instituting treatment. It is sufficient 
usually to fit the arm in a sling and immobilize the scapula by adhe- 
sive strapping. 

Fracture of the neck (Fig. 227) is of importance because it may be 
mistaken for fracture of the surgical neck of the humerus but in such 




Fig. 227. — Fracture of the neck of the 
scapula. 



e 



FRACTURE OF THE SCAPULA 295 

a case the head can be felt to rotate, which it would not do in disloca- 
tion. The deformity disappears on lifting the arm forcibly upward 
with the elbow flexed, which does not happen in a case of fracture of 
the humerus; the arm hangs vertically at the side and is mobile. 
There is no notching of the deltoid. 

In the case of fracture of the surgical neck of the humerus with 
overriding, the arm is shortened. In case of fracture of the scapular 
neck, the arm is lengthened. 

Generally speaking, the diagnosis of any fracture of the scapula is 
to be made from crepitus, abnormal mobility, local tenderness, and 
more or less complete loss of certain functions. Begin the examina- 
tion by inspection and measurement. Note any loss of contour; 
any lengthening or shortening of arm. To elicit crepitus, apply one 
hand to the body of scapula and with the other make traction on the 
arm. In thin subjects the lower end of the scapula may be readily 
grasped. 

Treatment. — The flexed elbow should be well supported by a sling, 
and the arm fixed at the side. Massage will relieve the pain and 
hasten repair. Mayor's sling furnishes an excellent dressing. 

FRACTURE OF THE RIBS 

Fractures of the ribs occur most frequently between the fifth and 
ninth, and are usually single and without displacement. If the 
violence is sufficient to break a number of the ribs simultaneously, 
it may cave in the chest wall; and, by perforation of the lung, 
produce emphysema, hemoptysis, pneumothorax. Pain and crepitus 
point to the presence of fracture. Detect crepitus by laying the 
palm over the site of the pain or by the stethoscope. 

Slight displacements may be reduced by making pressure over 
the site of fracture during inspiration, or perhaps by compressing 
the chest from front to back between the two hands. Apply ad- 
hesive strips 2 inches wide over the injured side, beginning at the 
scapula, and following the course of the ribs around to the sternum. 

Three or four strips may be necessary, and they must be applied 
at the end of expiration. 

The pain will almost always be relieved by such immobilization 



296 



FRACTURES OF THE CLAVICLE, SCAPULA, RIBS, ETC, 



of the chest wall. Those fractures which involve the viscera are 
considered with injuries of the thorax. 



FRACTURES OF THE VERTEBRA 

Fractures of the vertebra derive their chief importance from the 
accompanying injury to the spinal cord and are serious in proportion 
to the amount of injury to the cord, ligaments, and tendons. 

Aside from local pain and deformity, the symptoms are such as 
arise from compression or laceration of the cord and vary somewhat, 
depending on the particular portion of the cord involved. Fractures 

of the cervical vertebra are at 
once the most common and 
fatal. Fractures in the lumbo- 
dorsal region occur next in fre- 
quency. The break which 
usually involves the body of 
the vertebra, but may include 
the lamina or transverse or 
spinous processes, is generally 
due to forced flexion. Along 
with the fracture the ligaments 
are lacerated, the muscles torn, 
the vertebra displaced and the 
blood vessels opened. There 
may be present paraplegia and 
disturbances of the functions 
of bowel and bladder; and in 
addition to these symptoms 
there are certain others which are common to fractures of the 
vertebra wherever located, such as pain, tenderness to pressure 
and motion. Occasionally one will find deviations and angular 
deformities (Fig. 228). 

The prognosis in a well-defined case is always bad, although by no 
means always hopeless. 

The emergency treatment is limited generally to transportation and 
securing the proper bedding. The patient must be handled with the 




Fig. 228. — Fracture of vertebra. (Moullin.) 



FRACTURE OF THE SPINE 297 

greatest care. Sometimes the least added pressure on the cord by 
the movements of the spine may produce immediate death. 

The bed must be uniformly soft and smooth. A water bed is ideal. 
If the symptoms of compression are urgent, it is necessary at once to 
make an effort to reduce the fracture by simultaneous traction and 
pressure. While the assistants pull on the head and feet, the doctor 
attempts, by pressure, to correct the deformity. There is some 
danger of a fatal asphyxia where the fracture is high, in making these 
manipulations, as the patient is turned on his face and the move- 
ments of the diaphragm may be interfered with. Laminectomy is 
not to be considered when the indications point to complete crushing 
of the cord. In other cases where the pressure symptoms are 
obvious, a laminectomy should be done with delay. (See Wounds of 
the Spine.) 

FRACTURE OF THE PELVIS 

Fracture of the pelvis may be suspected from the character of the 
injury, which is usually a fall or a crush. The diagnosis is to be con- 
firmed by external palpation of the ilium, pubes, and ischium on each 
side, and by careful rectal and vaginal examination. Disturbance of 
normal relations, tenderness on pressure, crepitation perhaps, and 
difficulty in walking indicate fracture (Fig. 229). 

The prominence of the symptoms will depend in some degree upon 
the amount of displacement. 

The X-ray of course will be used whenever available. 

The treatment in the uncomplicated cases is simple. Usually 
nothing can be accomplished in correction of the displacement and 
simple rest in bed with adhesive strapping represent the elements 
of relief. Two recent cases in the City Hospital treated in this 
manner recovered in six weeks. It is quite different if there are 
complications. 

If a catheter cannot be passed (and this should always be tried), 
it will be necessary to do an external urethrotomy for the ruptured 
urethra. If the catheter finds the bladder empty and ruptured, a 
laparotomy is imperative. If the exact complications cannot be 
determined arid yet shock, pain, and increasing abdominal tension, 



298 



FRACTURES OF THE CLAVICLE, SCAPULA, RIBS, ETC. 



with signs of sepsis, point to a lesion of bladder or rectum, the abdo- 
men must be opened, and the visceral injury found and repaired. 

A woman was brought into the City Hospital the victim of an 
automobile collision. She was in full shock and the pelvis was 
plainly disarranged. The shock improved a little but the pulse re- 
mained rapid and weak. A catheter brought only a little blood 
from the bladder. A laparotomy showed the bladder to be greatly 




Fig. 229. — Fracture of the pelvis through the obturator foramen and dislocation 
at the sacroiliac joints. (Moullin.) 



contused, but not torn and there was much blood in the cellular tis- 
sues around; a large hematoma had formed under the pelvic perito- 
neum. Suprapubic drainage was applied but the patient lived only 
a few hours. Shock, the hemorrhage, and beginning infection were 
beyond the limits of her resistance. 

Following a variety of traumatisms there is often a condition now 
well recognized as relaxation of the sacroiliac synchondrosis which 
simulates fracture and which may become quite chronic. It is re- 
lieved by adhesive strapping. 









CHAPTER XVII 
FRACTURES OF THE SKULL AND FACE 

Fractures of the skull are important practically only from the 
point of view of their complications, which number three; infection, 
hemorrhage, and injury to the brain. 

In a given case, one or all of these complications are possibilities, 
although for the development of each, certain combinations of 
circumstances are peculiarly favorable. 

With respect of these variations, fractures of the skull are of two 
classes: fracture of the base and fracture of the vault. Each has its 
special symptomatology and prognosis, though the one may merge 
into the other and the clinical picture be more or less blurred. 

Either may be fissured, fragmented, or compound, with or with- 
out depression. In either the immediate gravity depends upon the 
nature and extent of the injury to the brain, and fractures of the base are 
the more serious, merely because the more important areas of the brain 
are there. 

With regard to the remoter consequences also, fractures of the 
base are less favorable; hemorrhage and its resultant complications 
are more to be feared; and infection is a more certain eventuality 
owing to the communications opened up between the cranial cavity 
on the one side and the ear, the nose, or the pharyngeal region on the 
other. 

The symptoms in either kind of fracture are such as arise from 
concussion, compression, or laceration of the brain and are general 
or focal, that is to say, emanating from certain cerebral areas. 

FRACTURES OF THE BASE 

Fractures of the base of the skull are more frequently indirect, the 
force being transmitted through the spinal column from some part 
of the vault or the ramus of the jaw; occasionally direct by a thrust 

299 



300 FRACTURES OF THE SKULL AND FACE 

through the mouth, a blow on the root of the nose, or upon the 
mastoid process. 

Any or all of the fossae may be involved. Fracture through the 
middle fossa is most frequent, and the most serious is fracture through 
the posterior fossa. These fractures are usually linear because the 
force is indirect and because there is only one determinable table 
instead of two, as in the vault. 

These fractures are nearly always compound, which adds to the 
gravity of the prognosis. The external meatus, the nasal cavities 
and the naso-pharynx are all prolific sources of meningeal infection. 

The diagnosis is usually by inference, often impossible. There 
are certain symptoms always suggestive of fracture at the base, 
but not to be relied upon exclusively. 

Ecchymosis in the tissues about the orbit, or hemorrhage into the 
sclerotic, appearing first some little time after the injury, and 
gradually progressive — -fracture through the anterior fossa suggests 
itself. Persistent bleeding from the nose following head injury must 
be given due consideration. Bleeding from the external meatus, 
copious and persistent, suggests fracture through the middle fossa. 
Late ecchymosis over the mastoid or into the tissues of the back of 
the neck suggests fracture through the posterior fossa. The dis- 
coloration follows the posterior auricular artery. However, these 
hemorrhages must not be mistaken for local rupture of mucous 
membrane or other soft parts and their absence does not necessarily 
mean absence of fracture. 

The bleeding, if intra-cranial, may come from rupture of the 
middle meningeal, or the internal carotid, or the sinuses. Instead 
of the bleeding, or accompanying it, there may be escape of cerebro- 
spinal fluid. Its presence is pathognomonic of fracture of the skull, 
and it must be distinguished from ordinary serum and the fluid of 
the middle ear by these characteristics: the flow begins at once and 
continues for several hours; the quantity is considerable, sometimes 
a tablespoonful in fifteen to twenty minutes; the flow is temporarily 
increased by the increase of intra-cranial pressure, sneezing, cough- 
ing, and vomiting; alkaline in reaction; contains only a trace of 
albumin and is rich in sodium chloride. 

Useful in definite diagnosis are the paralyses of the cranial nerves. 



FRACTURES OF THE SKULL 301 

Recall their origin, course, and functions. The facial, optic, and 
tri-facial nerves are especially likely to be involved. For example, 
the optic nerve will be involved if there is a fissure of the optic canal. 
Vision may be lost totally and immediately; even though total at 
first, the blindness may gradually pass away. It will be impossible 
for some time to say whether the recovery will be permanent. Added 
to these nerve symptoms, but not particularly helpful in the diagnosis 
of fracture, may be those of concussion, compression, or laceration. 
All these conditions may exist with or without fracture. 

The treatment has two ends in view, the prevention of further irri- 
tation of the brain and the prevention of infection. 

Keep the patient absolutely quiet in bed with the head elevated, 
apply ice-bags, and keep the bowels open. 

Whenever fracture of the base is even merely suspected, care- 
fully wipe out the external meatus and pack lightly with sterile 
gauze. Do not syringe the meatus or at least only very gently, lest 
infection be forced through the fissure. 

Remove the gauze as often as it becomes soaked with blood, which 
may be at frequent intervals for several days. Spray the nose and 
throat with peroxide of hydrogen or a similar mild antiseptic. These 
regions cannot be sterilized, but bacterial activity may be mini- 
mized. Do not pack the nares except for persistent nasal hemor- 
rhage, as the packing irritates the mucosa and unduly stimulates 
secretion, and this is undesirable. Again, such packing may excite 
a sneeze which by its explosive effect may carry infection through 
the fissure to the meninges. If packing is deemed necessary, pack 
with sterile gauze saturated with sterile vaseline. In the great 
majority of cases, active intervention is quite out of the question either 
for the relief of infection or for hemorrhage. But this is true merely 
because the technic is not definitely worked out. The principle of 
drainage for infection and removal of compressing clots applies with 
as much force here as in fractures of the vault (see Craniectomy). 

FRACTURES OF THE VAULT 

Fractures of the vault of the skull may be fissured, comminuted 
or compound, any one of which may be complicated by concussion, 
compression, contusion, or intra-cranial hemorrhage. The symp- 



302 



FRACTURES OP THE SKULL AND FACE 




'■ ■ '■' ' .. ■ ■ 



: 

■ 



toms belong to the brain complications rather than to the fracture 
itself. 

Simple, fissured fracture without depression is practically im- 
possible of diagnosis. The diagnosis is easier if depression is pres- 
ent, and yet certain injuries to the scalp simulate fracture with de- 
pression. A blow crushes the soft tissues and around the crushed 
area marked swelling ensues. The sensation to the examining finger 
is that of a depression of the bone. Do not be misled. 

Comminuted fracture of the 
skull even without depression 
is generally diagnosed, and yet 
a hematoma may mask the 
fragmentation. Be on your 
guard in that matter. 

The inner table is always 
more injured than the outer 
(Figs. 230, 231). 

The prognosis is good and the 
treatment simple in fissured 
fracture without depression and 
without symptoms indicating 
compression. 

Put the patient to bed, keep 
the bowels open, limit the diet, 
and await developments. Un- 
interrupted recovery usually follows, yet the exceptions to this rule 
are not infrequent and one must be on his guard for intra-cranial 
hemorrhage. Or later, there may develop symptoms which are 
explainable only on the hypothesis of contusion of the brain. 

If at any time symptoms arise indicating the occurrence of hemor- 
rhage, say from a rupture middle meningeal, immediate interven- 
tion is indicated. Some surgeons go so far as to recommend tre- 
phining for every fracture of the skull and exploratory operation 
in every suspected case, but that seems at the present time too 
radical, especially for the general practitioner left to his own 
resource. 

If the fracture is comminuted or even only fissured, with depres- 




Fig. 230. — Fracture of outer table from 
impact of a hammer. (Moullin.) 



COMPOUND FRACTURES OF THE SKULL 



303 



sion, the chances are so great that there is an injury to the brain 
that even with no symptoms present, immediate operation is indi- 
cated. (See Urgent Craniectomy.) 




COMPOUND FRACTURES OF THE VAULT 

Much more serious from every point of view are the compound 
fractures of whatever origin. The constant element of danger is 
infection. Add to this concussion, contusion, or laceration of the 
brain, and the outlook is grave 
indeed. The treatment is not 
so simple, but its purpose is 
quite definite, viz.: to prevent 
infection. 

This is accomplished not by 
keeping the bacteria out of the 
wound — they are already in; 
not by destroying them with 
strong antiseptics, as these are 
too injurious to the brain tis- 
sues, but rather by removing 
the conditions favorable to 
bacterial growth. 

To this end operation is im- 
perative. As in gunshot frac- 
tures, enlarge the wound, re- 
move extraneous matter, ele- 
vate depressed fragments, check the hemorrhage and remove clots, 
trim away devitalized tissues and provide drainage {See Craniectomy). 
Careful attention to these details results in the starvation of the 
germs present, with the result that repair proceeds. 

Skill in diagnosis, prognosis, and treatment in fracture of the skull 
depends upon a clear understanding of the mode of causation and 
the symptoms of contusion, compression, and concussion of the brain. 

Although presenting quite a diverse clinical picture, separately 
considered, these three conditions are nevertheless of the same 
origin fundamentally. They are each merely a complex of symp- 
toms expressing, on the one hand, varying degrees of either functional 



Fig. 231. — Same; fracture inner table. 
Xote greater comminution and depression. 
(Moullin.) 



304 FRACTURES OF THE SKULL AND FACE 

depression or stimulation of the cortex of the brain or, on the other, 
of the deeper centers of the cerebrum and medulla. The cortex is 
the seat of consciousness and at the same time the most sensitive 
part of the brain; therefore it is the first to be affected by conditions 
disturbing the circulation of the brain. 

The deeper centers, those governing respiration and circulation, 
are not so readily affected. The result is that loss of consciousness 
is the first phenomenon following a general disturbance of traumatic 
origin. This trauma may not be sufficient to reach the cardiac and 
respiratory centers at first or at all; or it may only stimulate them; 
or finally it may paralyze them as well as the cortex. It must like- 
wise be constantly remembered that stimulation of these basal 
centers means retardation of pulse and respiration; depression of 
the same centers means acceleration of pulse and respiration, and 
acceleration is an indication of approaching failure. 

It is only by reference to these first principles that one may ex- 
plain and reconcile the variations in the derangements of these 
functions of consciousness, circulation, and respiration in different 
cases. 

CONCUSSION 

This is in all probability due to a molecular disturbance of the 
brain substance, and is accompanied by neither microscopic nor 
macroscopic change. The disturbance may be (a) moderate, (b) 
severe, or (c) profound. 

(a) The disturbance is moderate. Under these circumstances, 
the trauma diminishes the function of the cortex, but does not affect 
the deeper centers of the brain and medulla, so there is therefore only 
a fleeting loss of consciousness without any change whatever in the 
pulse and respiration. 

(b) The disturbance is severe. The force depresses the cortex, but 
only serves to stimulate the deeper centers, and, as before, there is 
loss of consciousness, but there is this time slowing of pulse and 
breathing. Very soon the normal rate returns and a little later 
consciousness is restored. 

(c) The disturbance is profound. The cortex is paralyzed and 
profoundly depressed as are also the deeper centers. The result 



CONXUSSION 305 

is loss of consciousness and this time rapid and weak pulse and shal- 
low breathing which may terminate very shortly in death. In 
doubtful cases, then, the heart is the chief element in prognosis. 
The pulse immediately grows either worse or better. 

Therefore the symptoms of concussion are distinctly fugacious. 
This is its chief criterion. 

If the symptoms once improve and later recede, one may be sure 
the primary concussion is complicated by compression or contusion. 
Added to these phenomena of concussion, though not particularly 
helpful in diagnosis or progriosis, are certain other occasional symp- 
toms, referable to the reflexes. 

In the severe cases this will usually be the picture: At the moment 
of injury, unconsciousness occurs, immediate and complete. The 
patient is more than unconscious, he is anesthetized. The face is 
pale and sunken and the whole body cool. The pulse is small, 
rapid, and irregular. The temperature is subnormal. The breath- 
ing is shallow and sometimes sighing. The urine and feces may be 
retained or pass involuntarily. Repeated vomiting is quite common, 
especially as consciousness begins to return. Following the return 
of consciousness, a stage of excitement occurs. The symptoms of 
this stage are those of meningeal irritation, and in uncomplicated 
cases rapidly subside. 

The treatment is quite definite. Disturb the patient as little as 
possible in getting him into bed. Lower the head at first and try 
to maintain the body heat with woolen blankets and hot-water 
bottles. Carefully stimulate the heart. To this end, apply a mus- 
tard draft over the heart and inject ether hypodermically or a 10 
per cent, solution of camphorated oil. Repeat these injections fre- 
quently, being guided by the pulse. Von Bergmann recommends 
inhalations of ether for the very weak and failing pulse. 

Do not forget artificial respiration. In those severe cases where 
the respiration is dangerously low, it will sometimes tide the patient 
over the danger-line. 

In the subsequent stage of congestion, keep the head elevated 
and apply ice-caps if the dressings will permit. Keep the bowels 
open. If the excitement and restlessness are pronounced, mor- 
phin hypodermically is indicated. 
20 



3P6 FRACTURES OF THE SKULL AND FACE 

COMPRESSION 

Any condition, traumatic, inflammatory, or neoplastic, which 
diminishes brain room, may induce symptoms of compression of the 
brain. The symptoms and their course will vary according to the 
manner in which the pressure is produced. 

What is said here applies particularly to the pressure symptoms 
originating in depressed fracture or traumatic hemorrhage, though 
much would apply equally well to the pressure of brain abscess or 
brain tumors, or meningeal exudates and similar conditions. 

Pressure symptoms have fundamentally the same origin as con- 
cussion symptoms, that is to say, they are an expression of de- 
pression or of stimulation of the functions of the cortex and the auto- 
matic centers. In both there may be initial stimulation and terminal 
paralysis. However, this depression or stimulation is produced 
differently in the two conditions, concussion and compression. 

In the first case, the disturbance of function is brought about by 
mechanical injury and in the second by interference with the blood 
supply. Sudden diminution in the circulation modifies the func- 
tional activity of the brain centers. 

The cortex, the most sensitive, is first affected, followed by loss of 
consciousness. The automatic centers are next affected, at first 
stimulated, though each reacts differently; thus the respiratory center 
is the first to be stimulated and by the presence of carbon dioxide 
which was its primal stimulus. The vaso-motor centers are next 
invaded, and finally the vagal and convulsive centers. 

In those cases where the circulation becomes gradually slower, 
the order in which these centers and areas are successively affected 
is as follows: the cortex, the corona radiata, the gray matter of the 
spinal cord, the pons, and finally the medulla. Now the symptoms 
originating in these various areas as a result of pressure are of two 
kinds: 

(a) General or indirect. 

(b) Focal or direct. 

Each may manifest itself in two stages: 
(i) Stage of stimulation. 
(2) Stage of depression or paralysis. 



COMPRESSION 307 

It is the knowledge of these facts which enables us to harmonize 
and reconcile the diverse statements of various observers regarding 
the character and cause of the symptoms of compression. It is in 
the hemorrhage arising from the middle meningeal artery that the 
emergency surgeon is chiefly interested. Traumatic compression 
sufficiently serious to require immediate operation in nine cases out 
of ten originates in: 

BLEEDING FROM THE MIDDLE MENINGEAL ARTERY 

This may follow injury to the head with or without fracture. The 
fracture may or may not be diagnosed. 

In a typical case the concussion symptoms which supervened im- 
mediately upon the injury disappear after a half-hour. The patient 
regains consciousness, and the pulse and respiration approximate 
the normal. 

In the meantime, however, the blood from the torn meningeal is 
slowly oozing into the space between the dura and the skull, and the 
"free interval" is interrupted by headache, irritability, perhaps 
delirium (stimulation of the cortex). The epidural clot grows 
larger, the intra-cranial circulation is more impeded and complete 
loss of consciousness occurs (depression of the cortex). Coincident 
with this, the pulse grows slower and stronger, the respiration deep 
and stertorous (stimulation of automatic centers). A little later 
coma is profound, the respiration begins to fail, and the heart's 
action grows rapid, weak and irregular (depression of both cortex 
and automatic centers), and finally all the functions of the entire 
organ are suppressed and paralyzed, and death ends the scene. 

Along with these general symptoms there frequently occur at 
various stages certain focal symptoms, monospasms, convulsions; 
monoplegia or hemiplegia. 

Usually at the time the decision to operate is made, this will be the 
condition of the patient: He lies inert, unconscious, the pulse full 
and bounding, the respiration deep and stertorous, the skin hot and 
perspiring, the pupils irregular, usually dilated on the side of com- 
pression, partial or complete hemiplegia of the opposite side. 

Treatment. — -With a definite diagnosis once made, there is no 



308 FRACTURES OF THE SKULL AND FACE 

difference of opinion as to the treatment. It is imperative to operate, 
and to do so without delay. Every additional hour adds to the 
certainty of a fatality. The nature of the injury and the focal 
symptoms point to the site of the clot or the branch of the meningeal 
most probably involved. 

By trephining, the clot is exposed, and removed, and the bleeding 
vessel discovered and ligated. (See Craniectomy.) 

The pressure symptoms of hemorrhage from injuries of the sinsues 
are identical with those from meningeal bleeding except that they 
develop much more slowly and are likely not to be so typical. 
Hemiplegia is not always in the side opposite the clot. 

FRACTURE OF THE SUPERIOR MAXILLA 

Fracture of the superior maxilla occurs alone or with fracture 
the malar or other bones of the face. It may be accompanied by 
splintering of the bone, caving of the antrum, loosening of the teeth, 
and disfigurement generally. The alveolar process may be broken 
off. If this is the case, it may be replaced without great difficulty. 

Oftentimes little can be done to correct the deformity. The lower 
jaw can be used as a splint and very little force is needed to retain 
the fragments in position. 

If the fracture is compound, the fragments should be treated con- 
servatively. It is surprising how perfectly they may sometimes be 
repaired. The vascularity of both bone and periosteum favors this 
result. 

With the jaw at rest, a liquid diet should be maintained, frequently 
cleansing the mouth with alkaline antiseptic fluids. Be on guard for 
fracture of the base of the skull. 

FRACTURE OF THE MALAR BONE 

Fracture of the malar bone seldom follows the suture lines. The 
whole bone may be dislocated in a direction corresponding to the 
force. In this manner, the violence may be transmitted to the supe- 
rior maxilla, its sinus and infra-orbital canal, to the nose, the orbit, 
or to the base of the skull. 



FRACTURE OF THE LOWER JAW 309 

Uncomplicated fractures of the malar bones require little treat- 
ment. Compound fractures must be treated on general principles. 

It may be possible to replace a depressed fracture of the zygomatic 
process by pressure through the mouth. 

FRACTURE OF THE NASAL BONE 

Aside from gunshot fractures (see page 190), the bones of the face 
suffer occasionally from direct violence. 

The nasal bones may be fractured alone or in connection with the 
ethmoid. Bleeding is profuse and deformity apparent. On account 
of infection from either the outside or inside of the nasal cavity, 
inflammation and necrosis may be a sequela. 

An attempt should be made at once to elevate the depressed frag- 
ments by pressure within the nasal cavity. The reduction may be 
both difficult and painful. General anesthesia may be necessary. 

Check the hemorrhage by mopping the nasal cavity with a solution 
of adrenalin chloride, or pack temporarily with sterile gauze. Sub- 
sequently douche the nasal cavity frequently with glycothymoline or 
Seller's solution to prevent infection. 

FRACTURE OF THE INFERIOR MAXILLA 

Fractures of the inferior maxilla occur most frequently just in 
front of the mental foramen, and are usually compound, opening into 
the mouth. 

The deformity is determined chiefly by muscular action and the 
degree of obliquity. 

The diagnosis is rarely difficult. 

Reduction, which is indicated by a correct alignment of the teeth, 
may be accomplished by bimanual manipulation with the fingers of 
one hand in the mouth. This is usually easily done, the chief diffi- 
culty being to retain the fragments in position. The prevention of 
infection is likewise important (Fig. 232). 

Oliver, of Indianapolis (Ind. Med. Journal, 1906), has described 
the mode of treatment most applicable in the emergencies of general 
practice. He recommends, as the result of his experience, that in 



3io 



FRACTURES OF THE SKULL AND FACE 



the ordinary case, when the patient retains the majority of his teeth, 
the upper jaw be used as a splint. 

This is his procedure: before attempting reduction and without 
anesthesia, if possible, he begins by passing a loop of wire (soft iron 
wire, gauge 26 or 28) around the neck of the most available tooth 
behind the break in the lower jaw; a similar loop is thrown around the 
corresponding tooth in the upper jaw. Coming forward of the frac- 
ture the first solid tooth and its fellow 
above are both looped in the same 
manner. 

Next a similar loop is adjusted 
above and below on the opposite side 
of the jaw — on the sound side. Alto- 
gether six separate wires have been 
used. Each loop is now twisted down 
tight with a pair of pliers, so that the 
teeth are firmly encircled and the free 
ends of the wires left projecting from 
the mouth (Fig. 233). 

Reduce the fracture as the next step. 
This is done by pressure and traction 
with the fingers inside and outside of 
the mouth. 

Immobilize. — -This is accomplished 
by twisting firmly together by means 
of the pliers the corresponding upper and lower wires, which brings 
the lower jaw into intimate contact with the upper. 
Liquid diet sucked through the teeth. 

Antisepsis. — -Direct the patient to fill his mouth with the antiseptic, 
fluid and to churn it vigorously backward and forth between the 
teeth. This washing should be done frequently each day, and 
especially after each feeding. If necessary, as additional support, 
a plaster-of-Paris or Barton's bandage may be applied. 

The wires are left for three weeks, or longer in the severe cases, 
and after their removal a bandage should be kept on for another 
week. The patient should be supplied with a small pair of wire 
cutters and direct how to use them in an emergency, such as serious 
vomiting which might result in asphyxia. 




[Fig. 232. — Fracture of lower jaw. 
Temporary bandage. (Moullin.) 



SUTURING FRACTURE OF THE JAW 3II 

As Oliver observes, this formula may be varied to suit the indi- 
vidual case. The many forms of splints need not be here considered. 
The cases of special difficulty in reducing and retaining, those which 
are compound and those in jaws practically edentulous, require 
wiring. This is an operation simple in theory, but more difficult in 
practice. 




Fig. 233. — Wiring the teeth for fracture of the lower jaw. Note the manner in which 
the wires encircle the upper and lower teeth before and behind the line of fracture. The 
upper wire is subsequently twisted with its corresponding wire below, so that the lower jaw 
is splinted against the upper. 



The main points are to make the incision along the lower border 
of the jaw, cutting to the bone and letting the middle of the incision 
fall over the line of fracture. The bone is carefully denuded of 
periosteum. The sutures are not to come in contact with the buccal 
surfaces. The bones are drilled; the sutures passed and tied, the 
periosteum drawn over the sutures, and the soft parts partially 
repaired. 



CHAPTER XVIII 

INJURIES TO JOINTS 

Dislocations ; Compound Dislocations ; Open Wounds ; Contusions ; 

Sprains 

DISLOCATIONS . 

. Shoulder -joint. — Of all the joints, the shoulder is by far the most 
frequently dislocated. Of these dislocations, there are several forms, 
and yet only one variety is likely to be met with by the general prac- 
titioner — the sub-coracoid. A clear conception of the conditions and 
of the maneuvers necessary to a reduction presupposes a very defi- 
nite notion of the anatomy of the joint. 

Recall the relation of the acromion and coracoid processes to the 
glenoid fossa, to the head of the humerus and to the capsular liga- 
ment; the relation of the long head of the biceps to the joint and the 
attachments and actions of the various muscles surrounding the 
joint, particularly the subscapularis, the spinati, the pectoralis 
major; and the relations of the axillary vessels and nerves. 

However simple a case may appear, do not begin any maneuver 
until a complete diagnosis has been made. 

Diagnosis. — Begin by inspection. The patient is in evident pain; 
his head is inclined to the injured side and he supports the injured 
member with the other hand; the shoulder is flattened, the rounded 
prominence of the deltoid has disappeared and the acromion projects; 
the elbow is abducted and the patient is unable to bring it down to 
the side. 

Palpation reveals the axis of the humerus pointing to the middle of 
the clavicle; the examining finger can be pushed under the acromion 
where the humeral head should be. The humeral head itself may be 
felt below or to the inside of the coracoid, and rotates with slight 
rotation of the arm. 

312 



DISLOCATION OF THE SHOULDER 313 

The fingers in the axillary space feel the rounded head of the hu- 
merus projecting inward more noticeably when the arm is slightly 
abducted. 

These questions arise: "Is it a case of simple dislocation, or is it 
complicated by a fracture of the upper end of the humerus, of the 
great tuberosity, or the rim of the glenoid fossa?" "Have the arter- 
ies or nerves been injured?" You must test particularly for lacera- 
tion of the circumflex nerve. Do this by pin pricks over the deltoid; 
if the skin is insensitive, forecast paralysis and atrophy of the deltoid, 
and thus anticipate and disarm censure. 

Whether any of the other complications mentioned are present 
or not is to be determined by the methods already described in con- 
nection with fractures of the upper end of the humerus. 

Reduction. — (Lejars.) The method of Kocher seldom fails, if 
properly applied, and if the various movements are modified to suit 
the individual case. Its purpose is to put the head of the humerus 
in the position at w T hich it left the capsule. Through the relaxed 
tear the head is then to be levered into the socket. 

Seat the patient in a chair facing a little to one side. Let a strong 
and able assistant, standing behind, seize the patient's shoulder 
firmly and make pressure downward and backward. Place yourself 
before the dislocation, and seizing (in the case of the left arm) the 
forearm at the elbow with the left hand, and the wrist with the right 
hand, direct the patient to hold the head up and look straight ahead. 

First Stage: Flexion, Adduction. — The elbow is flexed and then 
gradually adducted until it touches the body, the wrist held firmly 
meanwhile. The elbow is now pushed backward beyond the axillary 
line — the first stage is not complete without this. Neglecting this 
part of the first maneuver is a frequent cause of failure. Do not 
get in too great a hurry. Remember that the larger part of the re- 
sistance is due to the muscles and that they yield only gradually. 
Too sudden and too violent traction on them augments the pain and 
their resistance. To pause a little now, gives them time to relax 
(Fig. 234). 

Second Stage: External Rotation. — Hold tr^e elbow fast and flexed 
at a right angle, and now with your right hand, swing the forearm 
outward and backward until it lies in the transverse vertical plane 



314 



INJURIES TO JOINTS 



of the body (Fig. 235). Its axis lies directly in front of you. Per- 
form the maneuver cautiously and smoothly. Again pause until 
the muscles are relaxed. Do not be alarmed by the snapping dis- 
tinctly heard in the movement. One may follow the movement 




Fig. 234.— Reduction of shoulder. First stage: Flexion; adduction; elbow a little 

posterior to the axillary line. 



of the bulging head of the humerus with the eye. Occasionally 
reposition occurs at the end of this movement, if it has been carried 
out methodically. If it has not proceed to the third stage of the 



maneuver. 



DISLOCATION OF THE SHOULDER 



315 



Third Stage: Elevation. — Maintaining flexion and external rota- 
tion, next lift the elbow upward and forward — upward and forward 
exactly — do not permit the elbow to move outward. Abduction 
will spoil the maneuver (Fig. 236). Lift upward and forward till 




Fig. 235. — Reduction of shoulder. Second stage: External rotation until fore- 
arm stands at right angle to body. 



the arm reaches the horizontal — a sudden snap indicates that the 
head has slipped into the socket. 

Fourth Stage: Internal Rotation. — Proceed now rapidly to swing 
the forearm inward and across the chest until the hand rests on the 



316 



INJURIES TO JOINTS 



opposite shoulder (Fig. 237). The movement is made rapidly but 
with no great force. This latter holds good with respect to all the 
movements. It must be observed that the surgeon's hands do not 
change their hold at any stage of the reduction. 











Fig. 236. — Reduction of shoulder. Third stage: Elevation while maintaining 

external rotation. 



If these maneuvers fail, repeat them in the same order, using a 
little more force in the second and third stages and pausing a little 
longer at the end of a stage. 

In the subclavicular form also this maneuver will succeed, but 



DISLOCATION OF THE SHOULDER 



317 



should be modified to this extent: prolong the second stage two or 
three minutes, using more force to obtain external rotation and the 
backward position of the elbow. In this wise, the muscles are re- 




FiG. 237. — Reduction of shoulder. Fourth stage. Internal rotation. 



laxed more completely. Without changing the external outward 
rotation, the elbow is lifted upward and forward as before. 

Not less efficient in certain cases of subcoracoid dislocation is the 
method of Mothe, or traction in extreme abduction. It is also applicable 
in all other forms of inward and downward dislocation. 



3i8 



INJURIES TO JOINTS 



In this procedure, counter-extension is indispensable. A long towel 
will serve. It encircles the injured shoulder, passing under the arm- 
pit, and the two ends cross the back toward the south side. While 
the assistant makes forcible counter-extension, the operator manipu- 




Fig. 238. — Reduction of shoulder. Traction with high abduction. The axis of the humerus 
should be in line with the spine of scapula. Assistant steadies the shoulder. 



lates the arm. It is best that he stand on a stool or chair if not tall 
enough to make good traction upward. Now seize the arm above 
the elbow and the forearm near the wrist (Fig. 238). Flex the elbow. 
Next elevate the arm by extreme abduction until it is in line with the 
spine of the scapula. The arm, you must observe, does not reach the 



DISLOCATION OE THE SHOULDER 



319 



horizontal merely, it is elevated beyond that level. This is of the 
greatest importance. With the arm thus in extreme abduction, next 
make strong traction in that direction (Fig. 239). Assistance in trac- 
tion may be necessary; or one may confide the traction to an assistant, 




Fig. 230. — Reduction by high abduction and traction. Note manner in which the assistant 

steadies the shoulder. (Lejars.) 



while with the thumbs, one pushes against the humeral head in the 
axillary space. 

If this does not succeed, begin the second stage: 

Depress the arm rapidly and smoothly, letting the point of the 
elbow pass in front of the chest, all the while maintaining traction. 
This method occasionally fails for these reasons: 

(1) Traction with high abduction is not long enough continued. 



320 



INJURIES TO JOINTS 



The arm is depressed before the head has been sufficiently elevated by 
traction. , 

(2) The arm is lowered too slowly. 




Fig. 240. — Chipman's method of reducing dislocated shoulder. First stage. 
(International Journal of Surgery.) 



In neglected cases or in the very muscular, general anesthesia may 
be indispensable whatever the method, but force must then be em- 
ployed with still greater care, and it must be borne in mind, too, that 
incomplete anesthesia here is as dangerous as it is useless. The par- 
ticular danger of this method is laceration of the axillary structures. 
If general anesthesia is strongly contra-indicated, local anesthesia 






DISLOCATION OF THE SHOULDER 



321 



may be employed, injecting the joint and the tendons near their lines 
of insertion. How long after the injury reduction may be attempted 
cannot be determined by any rule, but by the conditions in the 
individual case. 




Fig. 241. — Chipman's method of reducing dislocated shoulder. Second stage. 
{International Journal of Surgery.) 

Chipman, of New London, Connecticut, suggests a method which 
must prove of value, especially to the doctor compelled to act without 
assistance. 

He describes his method thus (Int. Journal of Surgery, November, 
1906): Stand facing your patient. Gradually raise the dislocated 
21 



3 22 



INJURIES TO JOINTS 



arm to a horizontal position and place it on your shoulder with fore- 
arm flexed on your back. Direct the patient to pass the well arm 
under your arm and grasp the wrist of the injured arm with the well 
hand. Thus the patient's arms encircle your body, the injured one 
passing over one shoulder, the sound passing under the other (Fig. 
240). 

Second Stage. — Now direct the patient to sag downward, and the 
weight of the body drags the head of the humerus outward and up- 
ward, when you can easily return it to the glenoid cavity with your 
hands (Fig. 241). The dislocation is so easily and expeditiously re- 




Sub-coraccc'd 



Fig. 242. — Dislocation of shoulder. (Walsham.) 

duced that even the surgeon himself is surprised. There is the least 
possible additional injury, the least possible pain; there is no need of 
an assistant or an anesthetic. 



SUBGLENOID DISLOCATION 

This variety is always the result of forcible abduction of the hu- 
merus, the tear in the capsule falling below the glenoid cavity, and 
the head of the humerus remaining fixed there (Fig. 242). 

The diagnosis is to be made from the symptoms already described 
for the subcoracoid form, the only difference being that the elbow 
is further from the chest, the flattening of the shoulder more pro- 



SUBGLENOID DISLOCATION 



323 



nounced, the head^of A the humerus more readily Jelt in the axilla 
(Fig. 243). 

The redaction may be affected by Kocher's method, but perhaps 
the best method is that of extreme abduction with traction, which has 




Fig. 243. — Reduction of a subglenoid dislocation. Second stage. Gradual 
elevation with constant traction. 



already been described. The patient may be seated, but often must 
recline, for the weight of the pendent limb may be very painful. The 
injured member is grasped above the elbow with one hand, below the 
wrist with the other, flexed, slowly raised to form an obtuse angle 



324 



INJURIES TO JOINTS 






with the chest. In this position strong traction and counter-traction 
are to be made. Usually this succeeds, though it may help to press 
the head into place (Fig. 244). If traction and pressure are not suf- 











j 



Fig. 244. — Reduction of subglenoid dislocation. Third stage. Traction with high ab- 
duction and pressure on the humeral head. 

ficient to effect reduction after the muscles have been thoroughly 
relaxed, the arm is to be depressed as before described. 

Subspinous Dislocation. — In this case the shoulder is flattened in 
front and the examining finger finds a marked depression between the 
tip of the acromion process and the coracoid. The elbow is carried 



SUBSPINOUS DISLOCATION 325 

slightly forward and the arm rotated inward. The head of the hu- 
merus can be felt below the spine of the scapula. 

Reduction. — General anesthesia is usually necessary. Grasp the 
arm above the elbow; slightly abduct the arm; slightly increase the 
inward rotation (never rotate outward) ; make traction in a direction 
downward and forward. Pressure forward on the head is helpful. 

AFTER-TREATMENT OF SHOULDER DISLOCATIONS 

The task in any form of dislocation does not end with reduction. 
There is still the duty to restore usefulness as completely as possible, 
and to that end the subsequent care must be minutely regulated. 
The inclination is to immobilize the joint too completely and too 
long, fearing a recurrence of the dislocation. This enforced rest com- 
bined with injury is liable to produce atrophy of the muscles, stiffness 
of the joint, and protracted loss of function. The indications for 
after-treatment are various, depending upon clinical conditions. 

(A) An uncomplicated, easily reduced dislocation in a healthy 
strong adult: 

Begin by immobilizing the shoulder, but take care that after three 
or four days of complete rest massage and passive motion shall be 
begun. The joint is cautiously put through all its motions, the del- 
toid, and pectoralis major, and the scapular muscles carefully mas- 
saged; a daily seance gradually prolonged. 

In the interval the arm is bandaged, but gradually the dressing is 
relaxed and, after a week, movement left quite free. In two weeks 
of such treatment the function may be entirely restored. 

(B) The case was complicated with injury to the soft parts, was 
with difficulty reduced, and only after a number of attempts; it is 
likely that the capsular ligament was extremely lacerated: 

Under such circumstances not only partial displacement, but 
actual dislocation is to be feared. Immobilize the joint with a Mayor 
sling or Velpeau bandage and let it so remain a week. But this will 
not prevent massage over the shoulder after four or five days. Do 
not prolong the fixation, remembering that a dislocation accompanied 
by great violence furnishes the condition most favorable to adhesions 
and weakness, and against these evils we have no remedies but mas- 
sage and gymnastics, which must be early begun and long continued. 



326 



INJURIES TO JOINTS 



A man was brought to the City Hospital with a pronounced sub- 
coracoid dislocation. The radiograph showed a part of the greater 
tuberosity scaled off. The injury was a crushing one, a great stack 
of sacks filled with flour having toppled over and pinned him against 
the wall. The tendon of the biceps was probably torn from its groove 
carrying a fragment of bone with it. Under general anesthesia the 
dislocation was easily reduced by traction with high abduction com- 
bined with pressure on the head of the humerus. After two weeks, 
immobilization the tenderness on pressure over the greater tuber- 
osity was still marked and it was assumed that the fragment was not 

yet reunited. Movement at the 
elbow also excited pain at the 
shoulder. After another ten 
days' massage and passive mo- 
tion was tried again with better 
results and at the end of five 
/ ' #i - s Jm 1 1 weeks he had regained the func- 

tions of the joint in fair degree. 




DISLOCATION OF THE 
LOWER JAW 

This accident, which may hap- 
pen at most unexpected times, 
when yawning or laughing, for 
instance, might be confused with 
certain fractures of the inferior 
maxilla. The opened mouth, the 
loss of power to close it, are 
characteristic (Fig. 245). The 
reduction is usually easy. Both sides may be reduced simulta- 
neously. Wrap the thumbs; you have to deal with the powerful 
muscles of mastication, which, when the dislocation is reduced, are 
likely to close the jaws with much force. 

The thumbs, passed into the mouth, press down ward and back ward 
on the molar teeth; at the same time, the fingers hooked under the 
chin pull upward. In the muscular, considerable force is required. 
The jaws should be moved only slightly for several days. 



Fig. 245. — Dislocation of jaw. (Moullin.) 






DIAGNOSIS OF ELBOW DISLOCATION 327 

DISLOCATION OF THE ELBOW 



Dislocation of the elbow, which occurs with considerable frequency, 
especially in children, nearly always assumes the form of backward 
displacement. 



Fig. 246. — Reduction of the elbow-joint. Traction with gradual flexion combined with 

pressure forward on the olecranon. 

Diagnosis. — The elbow is increased in thickness antero-posteriorly. 
The flexure of the joint is depressed. Where the head of the radius 
should be there is a depression. The olecranon is abnormally promi- 



328 INJURIES TO JOINTS 

nent. Compare the relation of the olecranon to the inner condylar 
lines on the two sides. Flexion is quite painful and practically 
impossible. 

If the diagnosis is doubtful, as it often must be when swelling is 
great, one thinks of supra-condylar fracture. But in the case 
of fracture, the relation of the olecranon to the condylar line is 
unaltered; the humerus is shortened; the deformity disappears with 
traction. 

Reduction. — (A) Standing on the injured side, seize the arm above 
the elbow with both hands, and as an assistant makes traction on the 
forearm, steady the arm and press with both thumbs on the olecranon. 
The traction is made at first in the direction- of the long axis of the 
forearm, but as the limb yields, the forearm is rapidly flexed — con- 
tinuing the traction and pressure. By this means reposition is usu- 
ally quite easy (Fig. 246). 

Traction and counter-traction as before, except that the traction 
which began in the direction of the long axis of the forearm and pro- 
duced flexion, now produces hyper-extension. In the meantime, 
press on the olecranon and the head of the radius. In this way, one 
will sometimes succeed, but do not forget this method is available 
only for those who have supple joints. 

(C) Method of Astley Cooper: 

The patient is seated on a chair — you place yourself on the side 
opposite the injured elbow. If it is the right, for example, stand upon 
the left side and place a foot upon the chair. Get the bend of the el- 
bow over the knee. Steadying the humerus with one hand, draw on 
the flexed forearm with the other, at the same time flexing the elbow 
over the knee. 

Generally speaking, however, if the first method fails, it is . bet- 
ter to give a general anesthetic, with which the chief difficulties 
disappear. 

Lateral dislocations are usually replaced without much trouble by 
pressure combined with extension. 

After-treatment. — This must be begun even earlier than for the 
shoulder — massage and passive motion — else a stiff joint is very 
likely to follow. 









CLASSES OF THUMB DISLOCATION 



329 




DISLOCATION OF THE THUMB 

This accident, apparently simple, presents some peculiarities, 
which must be borne in mind. 

These displacements at the metacarpo- 
phalangeal joint, are classified as incom- 
plete, complete, and complicated, de- 
pending upon the relations which the 
articular surfaces assume and upon the 
disposition of the sesamoid bone (Fig. 
247). Incomplete dislocations leave the 
articular surfaces in slight contact; com- 
plete dislocations find the articular sur- 
faces at right angles, the phalanx stand- 
ing upon the dorsum of the metacarpal 
(Fig. 248) ; and, if in addition to this, the 
torn anterior ligament and sesamoid 
bone, in attempt at flexion, are wedged 
between the articular surfaces, the dislo- 
cation is said to be complicated, a condi- 
tion difficult to manage (Fig. 249). Since 
this condition is produced by maladroit attempts at reduction of 




Fig. 247. — Complete dislocation 
of thumb. {Moullin.) 



-7\ 



- 




&& 




Fig. 248. — Complete dislocation 
of thumb. {Moullin.) 



Fig. 249. — Complicated dislo- 
cation of thumb. {Moullin.) 



the complete dislocation, it is especially desirable to understand 
the maneuvers. 



330 INJURIES TO JOINTS 

Whether the dislocation be complete or incomplete, never attempt 
reduction by flexion. That is the thing to be avoided. Seize the 
thumb and slightly bend it still further backward, at the same time 
pushing the base of the phalanx obliquely downward and forward. 
Directly the phalanx will be felt to slide over the head of the meta- 
carpal into its place. 

Complicated Dislocation. — (Lejars.) Employ general anesthesia. 
Only the most carefully regulated maneuvers will succeed. Do not 
attempt the reduction unless the various steps are clearly in mind. 

(i) Make traction on the digit in the direction of its axis until it 
is as long as normal. 

(2) Seizing the thumb between forefinger and thumb in such man- 
ner that your thumb presses on the dorsal surface of the dislocated 
joint, bend it backward until it stands perpendicular to the meta- 
carpal, or even further. The object is to put the thumb in the posi- 
tion of uncomplicated dislocation, and thus disengage the sesamoid 
bone. 

(3) Still holding it at that angle, push the base of the phalanx 
forward. 

(4) Having pushed the phalanx as far forward as possible in this 
manner, begin suddenly to flex it, in the meantime keeping the last 
phalanx extended and do not cease to push forward while flexing. 

If failure attends two or three attempts, do not persist; proceed 
to operate. 

Dislocations of the fingers should be treated in the same manner — 
never begin by flexing. 

Reduce by first bending the finger backward and then pushing 
the base of the phalanx forward. In every case the purpose is to 
reproduce in reduction the movements of dislocation. 

DISLOCATION OF THE HIP 

These accidents are always serious, and yet are comparatively rare. 
Of the different forms of luxation of the femoral head, the backward 
on the dorsum ilii is by far the most frequent (Figs. 250, 251). 

Diagnosis. — The thigh is adducted, rotated inward, and practically 
immovable. The leg is apparently shortened, the knee slightly 



DISLOCATION OF THE HIP 



33* 



flexed. The trochanter rests above the line drawn from the spine 
of the ilium to the ischial tuberosity. The femoral head may be 
felt under the gluteal muscles on the dorsum ilii. 

Reduction. — General anesthesia is usually necessary. Lay the 
patient on a pallet on the floor. A strong assistant, pressing on the 
iliac spines, immobilizes the pelvis. 

First Movement: Flexion of Thigh. 
— Grasp the thigh above the knee 
with one hand and with the other, 
the leg, and gradually flex the hip 
and knee. Flex the hip to a right 
angle. 

Second Movement: Traction on 
the Flexed Femur. — When the hip 
is flexed" at a right angle, begin 
traction, maintaining that angle. 
Do not be afraid to use force. 
This is the most important man- 
euver. Properly applied, that is to 4 
say, with powerful traction on the 
hip bent at a right angle, the effort 
will often be rewarded by a sudden 
snap, which indicates that the 
femoral head has returned to its 
socket (Fig. 252). 

Third Movement: External Rota- 
tion with Abduction. — Persisting in 
the traction, the resisting muscles 
are felt to yield. Now carry out the final maneuver, which should 
guide the head over the rim of the acetabulum into place. Continue 
traction to some extent, but rotate the thigh outward and at the 
same time abduct. All the other methods proposed are but modi- 
fications of this (Fig. 253). 




Fig. 250. — Backward dislocation, dorsum 
ilii; shortening, inversion. (Moullin.) 



ISCHIATIC DISLOCATION 



Diagnostic points: Adduction, inward rotation, marked flexion 
of both knee and hip (Fig. 254). 



332 



INJURIES TO JOINTS 






Reduction. — By the same method as the dorsum ilii. Do not begin 
the final movement of abduction and external rotation too soon. 




Fig. 251. — Dislocation of the femur upward and backward in a child. 
The arrow points to the acetabulum. 



SUBPUBIC DISLOCATION 

Diagnostic points: Compared with the ischiatic an opposite con- 
dition of affairs exists — abduction, external rotation and extension. 
The great trochanter cannot be located (Fig. 255). 

Reduction. — -Flexion is here illusory, and equally so, blind traction. 
Slightly lifting the extended limb, abduct it as far as possible; while 



DISLOCATION OF THE HIP 



333 



abducting continue to lift. The head rolls down toward the ob- 
turator foramen, and finally the thigh stands vertically. Now 
adduct and rotate inward. 




Fig. 252. — Reduction of the hip. Flexion of the knee. Gradual, flexion of 
the hip with traction on thigh. 



OBTURATOR DISLOCATION 



Diagnostic points: The hip is flexed, abducted, and rotated out- 
ward (Fig. 256). 

Reduction. — -Flexion of hip, traction on flexed thigh, adduction, 
inward rotation. 



334 



INJURIES TO JOINTS 

DISLOCATION OF THE KNEE 



This accident is infrequent, easy of diagnosis, and comparatively 
easy to reduce. 

General anesthesia is frequently necessary. Two assistants are 
needed, one for traction on the leg and one for counter- traction on the 
thigh, while pressure is applied at the joint. 




Fig. 253. — Reduction of hip. Third stage. External rotation. 
Hip strongly flexed. 



One must be concerned here with the condition of the blood 
vessels. Suppose there is no pulse at the ankle, the popliteal space 
is evidently filled with blood. Under these circumstances apply a 



DISLOCATION OF THE KNEE 



335 



tourniquet, and, under rigid antisepsis, open up the space by a 
longitudinal incision, turn out the clots, ligate the torn vessels. 
Remove the tourniquet, complete the hemostasis, and sew up the 
wound. The limb is bandaged in cotton, elevated, and kept warm. 





Fig. 254. — Dislocation of hip 
backward into the sciatic notch. 
Leg shortened, foot inverted. 
(Moullin.) 



Fig. 255. — Forward dislocation: 
subpubic; extension, eversion. 
(Moullin.) 



Time alone can tell whether or not the circulation will be restored 
and gangrene averted. 

DISLOCATION OF THE SEMILUNAR CARTILAGES 



This is an injury likely to be forgotten in making a diagnosis of 
disabilities of the knee. 

The internal semilunar cartilage is much more likely to be in- 



336 



INJURIES TO JOINTS 



volved, the accident usually occurring in this manner: the individual 
attempts to turn suddenly while the knee is flexed. The cartilage, 
either as a whole or, more often, a part, projects to the outside or in- 
side of the joint circumference. There is a sudden painful locking 
of the joint. 

The patient himself is often able to relieve the condition by a little 
manipulation of the joint, combined with lateral pressure. The 

injury is a serious one, functionally, and 
demands prolonged rest, in the hope that 
union may occur. An elastic silk stocking 
for the knee gives support and tends to 
prevent recurrence of the trouble, but 
violent movements are almost sure to 
bring a return. If asepsis is assured, the 
joint may be opened and the cartilage 
sutured to the tibia — -an operation to be 
advised by the general practitioner and 
yet scarcely ever necessary to be under- 
taken by him. 

DISLOCATION OF THE PATELLA 

The difficulties in correcting the dis- 
placement of the patella are various, de- 
pending not only on the character of the 
dislocation, but also on the condition of 
the ligaments and muscles. 

In general, there is one method of treat- 
ment, viz.: 

Extend the leg completely and, holding 

it in extension, flex the thigh to a right 

angle. By this means the quadriceps extensor, in whose tendon of 

insertion the patella is lodged, is relaxed, permitting the bone to be 

manipulated into place. 

DISLOCATION OF THE ANKLE AND TARSUS 

The diagnosis and correction of these injuries are more especially 
matters of anatomy. Whoever has clearly in mind the relations of 




Fig. 256. — Downward disloca- 
tion. Obturator. (Moullin.) 



DISLOCATION OF THE ANKLE 



337 



the components of the foot, can determine the character of the disar- 
rangement with the minimum difficulty. 

If the diagnosis is wrongly made, correct reposition is lacking, 
and in consequence there persists a degree of deformity and loss of 
function. 

One must begin his task of diagnosing a serious injury to the foot 
by recalling the relations of the malleoli and astragalus, the os calcis, 
and the other tarsal bones, to each other. 




Fig 257. — Backward dislocation of ankle with fracture of the tibia. 



Inspect the foot; the heel, the sole, the borders, the malleoli, the 
tendo achillis — and compare each of these, point for point, with the 
sound side. Remember that the line of the tibial crest, prolonged, 
falls on the second toe. 

A dislocation of the ankle-joint assumes various forms. The other 
bones may be dislocated from the astragalus, which retains its normal 
relation to the malleoli. There may be solely a dislocation of the 
22 



33* 



INJURIES TO JOINTS 



astragalus, which may take almost any position imaginable. Less 

often one finds displacement of the metatarsals and phalanges. 

There may be a fracture of the fibula (Fig. 257). 

It is scarcely possible to indicate an exact method of reducing 

such luxations. The surgeon's ingenuity must suggest the proper 

variations of traction combined with pressure. A type may be found 

in backward dislocations of the ankle (Fig. 
258). 

The malleoli are carried forward, the 
heel is elongated, the foot shortened. 
There is a transverse fold in front of the 
ankle, ridged vertically by the stretched 
extensor tendons. 

Reduction. — -The patient's foot projects 
over the end of the table, an assistant 
steadying the flexed knee. Grasp the 
heel with one hand and the middle of the 
foot with the other (Fig. 259). Make 
traction at first to reflex the opposing 
muscles and then shove the foot forward . 
and at the same time flex it. 
After-treatment. — -The injured joint, carefully padded, must be 

fixed by a plaster splint. After eight to ten days, passive motion 

and massage must be begun. 




Fig. 258. — Backward disloca- 
tion of ankle. (Moullin.) 



COMPOUND DISLOCATIONS 



These are accidents always to be dreaded, and yet they yield ex- 
cellent results under antiseptic methods. 

Before you is a joint wide open, the articular surfaces bare, per- 
haps protruding, and immediately you think of resection or amputa- 
tion, and yet you will do neither. You will proceed to do a most 
careful disinfection and to secure a complete reposition and immo- 
bilization. The one chief concern is disinfection. 

The same indications for treatment are present as in compound 
fracture into joints (see page 283) and depend upon the degree of 
injury to the soft parts and whether the infection is or is not obvious. 



COMPOUND DISLOCATIONS 339 

The skin about the wound is prepared as for a surgical operation, 
the wound is thoroughly flushed out with normal salt solution, foreign 
bodies are removed, and replacement is effected. The next step will 
vary, depending upon the degree of confidence in having completely 
sterilized the joint cavity. If the effort has been exacting in that 
regard, tightly suture the deep layers over the joint, close the super- 
ficial layers with interrupted sutures and apply drainage. 

If the articular structures were impregnated with dirt, one will 
still fear suppuration despite the greatest care in cleansing, and will 




Fig. 259. — Reduction of dislocated ankle. The assistant steadies the 
flexed knee. {Heath.) 

close the wound less firmly and provide for free drainage. Remov- 
ing as many bacteria as possible, starving those that remain by re- 
moving their food supply — -devitalized tissue and blood serum — -are 
the principles of treatment; cleansing and draining, the means; heal- 
ing without inflammation or suppuration, the end. 

Dressing and After-care. — -Having provided for drainage, cover the 
wound with sterile gauze, envelop the limb in absorbent cotton and 
immobilize the joint with a plaster splint. 

As soon as the soft parts are healed and the danger of infection has 
passed, begin massage of the muscles and slight movemeut of the 
parts daily. 

But in spite of careful cleansing, infection may develop. On the 
third day, perhaps, a chill occurs, the fever mounts rapidly and there 
are all the local signs of inflammation and sepsis. Do not temporize, 



340 INJURIES TO JOINTS 

t 

but immediately open the wound, douche thoroughly with peroxide 
or iodine water and leave the wound open. Immobilize. If the 
temperature does not fall and the local conditions do not improve in 
a few hours, proceed at once to do an arthrotomy (see page 440) . 

The thorough drainage by this means obtained will usually control 
the situation. The drainage is gradually withdrawn, and will not be 
necessary after about the tenth day. If, even then, the swelling and 
fever do not subside, there is nothing left to prevent a general in- 
fection but immediate amputation, and even that may be too late. 

The shoulder-joint rarely suffers a compound dislocation. Such an 
injury is especially serious for the reason that there are so many com- 
plications; the shoulder muscles are torn, the axillary vessels and the 
nerves of the brachial plexus lacerated. 

It must be treated on the general principles enumerated and the 
result is often surprisingly good. If traumatic aneurism exists, the 
pectoralis muscles must be divided, the space exposed and the vessels 
ligated. 

The hip-joint is occasionally the site of a compound dislocation and 
nearly always the shock is fatal. 

Elbow. — -This is a comparatively frequent accident and is treated 
on the general principles outlined. If the injuries are severe, a 
partial excision may be required to perfect drainage and insure a 
better joint. Amputation will be indicated only in old age, morbid 
constitutional disability, or extreme local destruction. 

An automobile overturning caught the driver in such way as to 
produce a compound dislocation of his elbow. He was brought in by 
the ambulance, with a tourniquet on the arm. 

Under a general anesthesia the wound was explored after cleansing 
with tr. iodine. 

The end of the humerus protruded through one ugly ragged rent. 
The brachial artery was torn, the ends widely separated. The 
brachialis anticus could scarcely be identified and the median nerve 
stood out prominently, stretched over the projecting bone. 

Reduction was accomplished, the torn vessels ligated, the tourni- 
quet removed and an effort made to suture the capsule. 

Next the torn brachialis anticus and the group of muscles attached 
to the internal condyle were repaired in a fashion, with chromic gut; 



COMPOUND DISLOCATION 



341 



the bicipital fascia was sutured also with chromic and the skin with 
silkworm-gut with slight drainage; the joint was fixed in flexion with 
plaster in the form of a posterior splint. 

On account of the ruptured brachial artery gangrene was feared 
but at the end of thirty-six hours a slight radial pulse was felt. There 
was much swelling and great pain, but scarcely any rise of tem- 
perature. 




Fig. 260. — Fracture and compound dislocation at the wrist. Hand saved. (Scudder.) 



Eventually a considerable slough occurred in the wound, but with- 
out evidence of infection. A month was required for repair of the 
wound. 

Under an anesthetic the limb was gradually extended and fixed in 
that position for a while. At the end of the sixth week it was flexed 
again, this time manipulated quite freely. 

The whole forearm remained very painful and the patient was un- 
able to move it. He insisted on amputation, but was encouraged to 
persevere with massage, the electric current and hot baths. Some 
improvement in the pain was secured and the patient began to work 
with the joint himself. From that time on the joint gradually re- 



342 INJURIES TO JOINTS 

sumed all its functions and at the end of six months he was driving 
his Ford as swiftly as before. 

The wrist should be treated conservatively. A loose carpal bone 
may require removal or partial resection. Amputation will be re- 
quired if healing is obviously out of the question (Fig 260). 

Compound dislocations of the knee-joint are very rare. If con- 
servatism fails, amputation is the only alternative. 

Ankle and Tarsus. — -These dislocations are frequent and require 
much attention. Antiseptic foot baths serve an excellent purpose 
though the primary cleansing must be especially vigorous. The 
tarsal bones may need to be sutured to be retained in place. Espe- 
cial care must be taken not to interfere with the circulation (see page 
288, compound fractures). 

CONTUSIONS OF THE KNEE-JOINT 

These are so frequent as to ca]l for a special word. The aim is to 
avoid an acute synovitis, which may become suppurative. In milder 
cases, rest in bed with some mild liniment and light massage will 
be sufficient, and the pain and stiffness will rapidly subside. 

In the severer cases, indicated by pain and swelling, more active 
measures must be instituted. 

Wrap the joint in absorbent cotton and apply a plaster bandage for 
two or three days. The uniform pressure will. limit the effusion and 
hasten its asbsorption. After that you may begin hot sponging and 
very gentle passive motion with massage, applied at first only to the 
muscles moving the joint, and afterward, as the tenderness subsides, 
to the joint itself. 

PUNCTURE AND STAB WOUNDS OF THE KNEE-JOINT 

The treatment will depend largely on the instrument which in- 
flicted the wound and the* appearance of the wound. If the wound 
is clean-cut, and the instrument presumably non-septic, content 
yourself with sterilizing the field of the wound, enveloping the knee in 
an antiseptic compress and putting the joint at rest, preferably in a 
plaster splint. You will anxiously watch the temperature. If it 
does not rise within three or four days, one may cease to fear infec- 
tion, and such swelling as appears is not significant. 






sprains 343 

It is quite different when the temperature begins to rise and the 
local symptoms gradually increase, or if the wound is seen after some 
days of neglect and the symptoms of infection are fully developed. 

Under these circumstances, there must be no delay. Immediate 
operation is imperative; it is indicated to do an arthrotomy, disinfect 
and drain (see page 440). 

This treatment, early and properly applied, will save the joint. 
As infection subsides, the drainage is gradually withdrawn. 

There are cases, however, in which, unfortunately, even these 
strenuous measures fail. In spite of immediate recognition of the 
urgency, and immediate action, laying open the joint with the ut- 
most freedom, followed by repeated irrigations — -in spite of the ut- 
most endeavor, the symptoms of grave general infection persist and 
it is necessary to amputate. This may save the patient's life — more 
often it will not. 

EXTENSIVE INCISED OR LACERATED WOUNDS OF 

THE KNEE-JOINT 

In these cases, it is never sufficient merely to cleanse the skin and 
seal the wound with antiseptic dressings. The wound must be en- 
larged, thoroughly cleansed, and the joint cavity irrigated with 
sterile water or normal salt solution and wiped dry with sterile gauze. 

After the complete disinfection, the wound in the capsule is sutured 
and, perhaps, also the skin. More frequently, however, one will 
feel safer to leave drainage in the skin wound. The joint is immobil- 
ized, and if everything goes well, the drainage-tube is removed after 
forty-eight hours. 

SPRAINS 

In general, these conditions are to be treated by firm bandaging for 
two or three days, to limit the swelling and hasten the absorption of 
the effusion; and then massage and slight passive motion are begun. 
It is better to give the joint functional rest until at least the greater 
part of the pain has subsided. 

The ankle-joint is more frequently sprained than any other, partly 
on account of its construction and partly on account of its function. 
The weight of the body falls on the insecurely poised foot and the 



344 INJURIES TO JOINTS 

ankle gives way under the load. The ankle usually bends outward 
and the external lateral ligaments are subjected to great strain. 
They are undoubtedly often lacerated or the capsular ligament may 
be torn. The pain in the severe cases is immediate and intense ; the 
patient may faint. If the joint is continued in use, the swelling is 
aggravated, but in any event swelling rapidly ensues. 

Morphine may be necessary to relieve the pain. If seen at once, 
the ankle is immobilized in plaster of Paris for a few days, or band- 
aged tightly with a flannel or rubber bandage, or strapped with adhe- 
sive plaster, after which massage and passive motion are employed. 
The patient should walk with crutches at first. The joint will be 
stronger than if it was used before the pain and swelling had subsided, 
although excellent authorities advise walking from the first. 

If adhesive strips are used, in order to avoid circular constriction, 
apply them in this manner: cut the adhesive strips }/& inch wide 
and in two lengths, 12 and 18 inches. 

(1) Begin with one of the long strips in front of the big toe, carry 
the strip back around the heel, keeping just above the contour of the 
sole, and bring the strip back across the dorsum of the foot to the 
starting-point. Overlap with this a similar strip. Both should be 
tightly drawn. 

(2) Begin with one of the shorter pieces above the ankle and carry 
it under the heel to the opposite side. 

The subsequent strips are applied alternately in this fashion, each 
overlapping the one preceding, until the foot is practically covered. 

The whole is then enclosed in an ordinary roller bandage and the 
foot kept quiet. After two or three days, the patient may begin to 
move around a little, but the dressing must be left on till the pain and 
swelling have subsided. It may be reinforced by additional strips 
placed over the loose ones. 

The manner of giving massage is also important. In the case of a 
tender joint, begin by gently stroking the healthy tissues just above 
the joint in the direction of the blood and lymph currents, and gradu- 
ally approach the joint. The movements are gradually made more 
vigorous, using the palmar surface of the hand. After a few minutes 
of this work, the joint will usually permit a direct manipulation and 
finally slight passive mQYQnient is begun. 



EUPTURE OF THE CRUCIAL LIGAMENTS 345 

RUPTURE OF THE CRUCIAL LIGAMENT OF THE KNEE 

An injury to the knee-joint often diagnosed as sprain, is rupture of 
the crucial ligament of the joint. This injury happens when violence 
is applied to the flexed joint at which time the anterior ligament is 
very tense. 




Fig. 261. — Rupture of the crucial ligament due to lateral blow on flexed knee. The X-ray- 
usually shows a portion of the tibial spine wrenched off. 

Turning suddenly on the flexed knee may produce the same result. 
The pain and disability are out of all proportion to the apparent in- 
jury, but the swelling is not extreme. The X-ray will usually in- 
dicate the nature of the trouble not because the ligaments cast a 



346 



INJURIES TO JOINTS 



shadow, but because some fragments of the bony attachments are 
avulsed. In fact in some cases "fracture of the tibial spine" is the 
better diagnosis (Fig. 261). 

Prolonged fixation in plaster is the proper treatment. Massage, 
manipulation, or limited use should not begin until repair is prac- 
tically complete, which will require at least two months; and^ven 
after that, a splint permitting restricted motion only may need to 
be worn. 



CHAPTER XIX 
INJURY AND REPAIR OF TENDONS 

There are three kinds of injuries to tendons which it is practical to 
consider as emergencies: dislocated tendons, subcutaneous rupture, 
and divided tendons. 

Dislocation of Tendons. — -Dislocation is not a frequent injury, and 
yet it occurs and is to be considered as a possibility in making a diag- 
nosis of disturbances of function after certain joint accidents. Every 
sprain should be examined with this point in view. 

The tendons most frequently dislocated are those of the peronei 
muscles, especially the brevis. Following a severe wrench of the 
ankle, it is torn out of its sheath behind the external malleolus and 
carried forward onto the malleolus, where it can be felt and moved. 

It is easily replaced, but it is with more difficulty retained. The 
ankle must be immobilized at a right angle to relax the calcaneo-fibu- 
lar ligament, and the tendon retained by pressure until the ruptured 
tendon sheath or lateral ligament is healed, which will require about 
four weeks. It will sometimes be necessary to expose the tendon and 
repair the rupture tissues. 

The long tendon of the biceps may be wrenched from its groove in 
the humerus and the loss of function and prominence of the head of 
the humerus may suggest dislocation of the humerus. As a rule, the 
tendon is easily replaced by a little manipulation, but the useful- 
ness of the arm will be impaired for a long time. 

The other tendons of ankle and wrist occasionally may suffer simi- 
larly, but not seriously. 

Subcutaneous Rupture. — -Subcutaneous rupture is especially likely 
to occur with the tendon of the quadriceps extensor or triceps cubiti 
or the tendo achillis. A sudden violent effort is the usual cause. 

The pain, the loss of function, the gap between the ends of the rup- 
tured tendon, and the history of sudden muscular contraction point 
to the nature of the injury. 

347 



348 



INJURY AND REPAIR OF TENDONS 



There is only one logical treatment, viz. : by an incision to expose 
the tendon at once and by some of the methods shortly to be de- 
scribed, reunite the parts by suture. It is the duty of the doctor to 
insist on nothing less (Fig. 262). But it must be remembered that 
the synovial sac is peculiarly susceptible to infection and the skin 
over the patella difficult to sterilize. 




Fig. 262. — Repair of ruptured tendon of quadriceps extensor femoris. d, tendon; c, 
basting stitches; b, sutures uniting posterior edges; a, sutures uniting anterior edges of 
ruptured tendon. (Bryant.) 



If this procedure is not followed, it remains only by position, rest, 
and massage to favor repair, which, at the best, will be uncertain 
and slow. 

The position must be such as to relax the muscle, the limb must be 
immobilized, and after the first few days massage must be begun 
and carried out systematically. 



INJURY OF TENDONS AT THE WRIST 



349 




Fig. 263. — Incised wound of back of wrist. Divided tendons exposed. iVeau.) 




1 Fig. 264, 



■"Expression" of retracted end of divided tendon by forced flexion and com* 
pression of forearm. (Veau.) 



3So 



INJURY AND REPAIR OF TENDONS 



The history of a case reported by Gage, of Worcester, Mass., is 
typical. A man, fifty-seven years old, slipped and fell with his left 
knee doubled under him. He could not lift his leg from the ground. 
Examination an hour later showed a gap 6 cm. wide between the 
upper border of the patella and the retracted edge of the quadriceps 
tendon. 




Fig. 265. — Exposure of tendons by enlarging wound in aponeurosis. 

tendons. (Veau.) 



Suturing 



Operation. — A transverse incision was made across the front of the 
knee and the ruptured tendon exposed. The rupture was complete 
except for a few fibers on the outer edge. The joint was exposed, 
the clots wiped out. The edges of the tendon were then carefully 
coapted with interrupted catgut sutures. The leg was put up in 
plaster-of-Paris splint for seven weeks. After that it was massaged 
daily and the splint. definitely removed at the end of twelve weeks. 
The leg became as strong and flexible as before the accident. 



SUTURE OF TENDONS 



351 



Divided Tendons. — These are found frequently, especially at the 
wrist. They must be immediately sutured for then 
it is relatively easy. Later they retract or acquire 
adhesions and it is difficult to approximate the two 
ends, and one must have recourse" to special 
maneuvers. 

Use No. i or No. 2 silk or chromicized catgut. 
A small curved needle or a straight sewing needle 
will serve. 

Begin by carefully disinfecting the wound and 
securing complete hemostasis. The lower ends of 
the divided tendons will usually be found near the 
lower lip of the wound (Fig. 263). Identify each 
and count them to be sure none have been over- 
looked. At the same time, see if a nerve has been 
divided. Look for the others of the divided ends. 
If they are not in sight, do not reach blindly for 
them with forceps, but attempt to bring them into 
view by " expression," and if this fails, boldly en- 
large the wound. 

Expression. — Direct the assistant to grasp the 
member above the wound with both hands and the 
pressure may force the tendons into view. If the 
extensor tendons are involved, employ forced flexion 
with the pressure. These muscular groups are more or less unified 

and the undivided tendons put 
on the stretch help to drag 
the divided tendons into view 
(Fig. 264). 

If this method does not suc- 
ceed, apply a roller bandage, 
beginning at the elbow-joint in 
the case of the upper extrem- 
ity; at the knee in the case of 
the leg or foot, and carry it 
down to within an inch of the 
wound. If this, too, fails, make a, free incision observing this point; 




Fig. 266. — One 
method of suturing 
tendon of medium 
size. (Veau.) 




Fig. 267. — Method of introducing suture for 
divided tendon. (Marsee.) 



352 



INJURY AND REPAIR OF TENDONS 




Fig. 268. — Suture of tendons completed. Repair of aponeurosis. The aponeurc 
should not be divided directly over the tendons else adhesions may occur. (Veau.) 





Fig. 269. — Suture of a flattened 
tendon. {Veau.) 



Fig. 270. — Suture of a lacer* 
ated tendon. (Veau.) 



SUTURES OF TENDONS 353 




do not make the incision directly over the tendon for it may later 
acquire adhesions to the scar tissue, interfering with its free move- 
ment. Generally with a little patience the tendon is found. It 
is often practical after incising the skin to make a diagonal incision 
of the deep fascia or two incisions at a right angle, creating a 
flap which may be dissected up and the tendon group well exposed 
(Fig. 265). 

Suture of the Tendon. — (A) The tendon is round, as at the level 
of the wrist-joint. Seize the tendon with a dissecting forceps, being 
careful not to bruise it. Pass a suture through the whole thickness 
Y± inch from the end (Fig. 266), entering the superficial surface 
and emerging on the deep surface of the segment and carrying it 
then to the other part; entering the deep surface and 
emerging on the superficial surface. The ends of the 
divided tendon are then coapted and the suture tied. 

The suture may be passed laterally instead of antero- 
posteriorly. If the ends of the tendon come together 
well, a suture may be entered }A inch from the divided 
end and passed obliquely in such a manner that it 
emerges from the cut surface and then is passed into 
the cut surface of the opposite end and emerges sym- 
metrically with the original point of entrance. Marsee 
advises passing a separate suture three times through 
the tendon, tying the corresponding ends (Fig. 267). 

Repair the wound in the deep fascia by a continuous 
suture, being assured once more that no nerve is divided 

< Fi s- 268) " 

(B) The tendon is flattened. In this case, the ends Method of 

must overlap. Make a latero-lateral anastomosis; pass elongating a 
the suture through the lower end from before backward, 
beginning near one border. Next pass the suture through the upper 
end from before backward and again from behind forward. Finally 
pass the suture from behind forward through the lower end. When 
the suture is ready to tie, the lower end overlaps the upper (Fig. 269). 

(C) The tendon is shattered or lacerated. In this case before sutur- 
ing tie a firm ligature around either end, which will prevent the 
suture from pulling out (Fig. 270). 

23 



354 



INJURY AND REPAIR OF TENDONS 





Fig. 272. — Suture by double anastomosis 
when the two ends of the divided tendon 
cannot be brought in contact. (Veau.) 



Fig. 273. — The upper end cannot be 
found. Suture to adjoining tendon. 
(Veau.) 




Fig. 2 74« — The long extensor of the thumb divided, the upper end lost. The adjoining 
tendon is split and one segment sutured to long extensor. (Schwartz.) 



SUTURE OF TENDONS 



355 



^(D) The tendon is voluminous. In this case it is better to vary the 
ethod a little. Pass the transverse suture as in Fig. 266. Before 
eying the suture, the posterior lips are drawn together as neatly as 
possible. When these sutures are all tied, finally suture the anterior 
lips together. Over all suture the deep fascia. The transverse 
suture must be strong, No. 3 silk for example, though the others 
may be finer. 

(E) The ends cannot be approximated. This will not happen ex- 
cept in the neglected cases. Two procedures are practical. 

(1) The space may be bridged by sutures, which will favor re- 
union by scar tissue. Begin by ligating both ends (Fig. 270) and 
then pass three to six sutures as the one is passed in the figure. 

(2) The space may be bridged by splitting the upper tendon in 
the manner indicated in Fig. 271. Before the tendon is split, it 




Fig. 275. — Plaster splint applied to maintain flexion. 



must be ligated near its end. In the case of the tendo achillis, it may 
be lengthened by making several half cross sections at different levels, 
first one side and then the other. 

(3) The two ends may be sutured to a neighboring tendon (Fig. 
272). 

(F) The upper portion of the divided tendon cannot be found. In 
this case, buttonhole a neighboring tendon, selecting one nearest 
resembling in function the divided one. Into the slit pass the end 
of the divided tendon and fasten with one or two sutures. The 
divided tendon should be slightly on the stretch when the suturing 
is completed (Fig. 273). 



356 INJURY AND REPAIR OF TENDONS 

The healthy tendon may be split and the separated portion sutured 
to the divided tendon (Fig. 274). 

Drainage. — -Drainage is necessary if the wound was accidental. A 
small drainage-tube is left beneath the skin. The fascia has been 
completely closed. Apply a dry antiseptic and absorbent dressing. 

Immobilize the part in a position, flexion or extension, to relax the 
tendons. If necessary, apply a plaster bandage over the dressing. 
An excellent splint is made by taking a plaster roller, properly soaked, 
and folding it back and forth, pressing the folds carefully together 
until a five- to eight-ply splint of proper width and length is made. 
This is slightly padded, bandaged in place and held at the necessary 
degree of flexion till the plaster hardens (Fig. 275). 



CHAPTER XX 



INJURY AND REPAIR OF NERVES 



THE REPAIR OF DIVIDED NERVES 



It is imperative to suture a divided nerve as soon as the condition 
is recognized. If the repair is made at once it is more easily done than 
the suture of tendons, for the ends are not so widely separated; but, 
on the other hand, it is more delicate work, for the trunks are smaller. 

Do not handle these tissues roughly and, above all, do not cleanse the 
wound with strong antiseptics, such as bichloride and carbolic acid. 

Remember that the upper part of the 
nerve retains its sensitiveness and in it are 
the essentials of repair. The lower seg- 
ment degenerates if repair is neglected. 

It is usually necessary to freshen the 
ends, but one must be very sparing of the 
tissues, removing less than a millimeter 
from each extremity, using fine sharp 
scissors. It is better to make the sec- 
tion oblique (Fig. 276). 

Pass a silk (No. o) suture or a small 
catgut with a round needle through the 
whole thickness, as in the case of a round 
tendon (Fig. 277), draw the ends together 
and complete the repair by suturing the 
lips, passing the suture through the 
nerve sheath only (Fig. 278). Adjust the ends exactly and always 
where possible make the suture an end-to-end one. 

Repair the various layers of fascia with great care, so that the 
sutured nerve may be isolated and removed from the sources of 
infection. Employ drainage in suturing the skin. 

357 



Fig. 276.— Ob- 
lique section of 
the nerve ends. 



Fig. 277. — 
Through and 
through suture 
of nerve. 

(Veau.) 



358 



INJURY AND REPAIR OF NERVES 



For the rest, the treatment is the same as for any other wound. 

Secondary Suture. — It may be found necessary 
to suture a nerve some time after the injury, and 
this operation will present difficulties. The ends 
may be separated or they may be imbedded in 
scar tissue. 

A knob often forms on the proximal stump. 
In such a case, freshen the ends and pass the 
suture in the manner pictured (Fig. 279). 

If the two ends are attached by a fibrous cord, 
split the scar tissue longitudinally (Fig. 280), and 
transform the longitudinal fissure into a transverse 
one and suture (Fig. 281). If the ends cannot be 
approximated or bridged they may be sutured at 
different levels to a neighboring nerve in the 
manner described under Repair of Tendons. 

Warn the patient that it may be a long time 
before function is even partially restored. In the 
o _ x meantime, muscular atrophy must be prevented 

Fig. 278. — Suture ' ^ . 

of nerve through by persistent use of electricity, and massage. 

the sheath. {Heath.) 




CONTUSION AND COMPRESSION OF NERVES 




These injuries to nerves are by no 
means infrequent, following blows, gun- 
shot wounds, machinery accidents, frac- 
tures, and dislocations. 

The symptoms vary from slight ting- 
ling to complete loss of function. The 
loss of function is often a later de- 
velopment, due to a neuritis following 
the contusion, and is accompanied by 
neuralgia, muscular palsy and trophic 
alterations corresponding to the distri- 
bution of the nerve. 

Treatment. — -The immediate indica- 
tions are to restore the parts to their normal condition as much 




Fig. 279. — Secondary suture. 
Method of coaptation. (Veau.) 



INJURY TO THE FACIAL NERVE 



359 



as possible, and to relieve the pain by hypodermic injections of 
morphine or by phenacetine and codeine. The nerve must be put 
at rest by immobilizing the limb. Later, alteratives, electricity, 
and massage are useful. 



INJURIES TO INDIVIDUAL NERVES 

Facial Nerve. — The facial is more frequently injured than any 
other cranial nerve: in fracture of the base of the skull; in the mas- 
toid operation as it passes 
through the temporal bone; 
by shots and blows at its 
exit from the styloid fora- 
men. Depending upon the 
distance of the lesion from 
the central origin of the 
nerve, there occur paralysis 
of the muscles of expression, 
disturbance of salivary secre- 
tion and the sense of taste, 
and paralysis of the palatal 
muscles. Injury to the 
facial nerve is often accom- 
panied by injury to the ab- 
ducens and auditory nerves. 

To Expose the Facial 
Nerve. — -The incision begins 
behind the external auditory 
meatus and extends down- 
ward and forward to the 
angle of the lower jaw. 

Divide the integument, superficial fascia and the first layer of the 
deep fascia. This exposes the parotid gland, the sterno-cleido- 
mastoid and the mastoid process. The posterior auricular nerves 
and the vessels are to be avoided. Carefully dissect and draw 
forward the part of the gland exposed and the posterior belly of 





Fig. 280. Fig. 281. 

The two ends of the nerve are connected by a 
fibrous cord which is split longitudinally and su- 
tured as indicated. (Veau.) 






360 INJURY AND REPAIR OP NERVES 

the digastric appears, just above which the nerve lies upon the 
styloid process. 

Optic Nerve. — -The optic nerves are injured most frequently in con- 
nection with fracture of the base of the skull involving the anterior 
fossa, and especially when the fissure involves the optic foramen 
for there the nerve is firmly attached to the bone. 

As a consequence of such injuries, there maybe compression, lacera- 
tion, or extravasation into the nerve sheath. As a result of these in- 
juries, there are disturbances of vision of various degrees. In ob- 
scure trauma of the brain, the ophthalmoscopic examination of the 
fundus of the retina should never be neglected as a means of diagnosis. 

Motor Oculi Nerve.— The motor oculi nerve may be injured by 
wounds penetrating the orbit and by fractures of the base. Its func- 
tion may be disturbed by pressure following the rupture of the middle 
meningeal artery and often the only indication of this disturbance is 
a dilated pupil and drooping of the eyelid. 

Patheticus and Abducens. — These nerves are often injured along 
with the third, producing loss of rotation and abduction of the eye ball. 

Fifth Nerve. — The fifth nerve is rarely injured alone, but injury of 
single branches may occur. 

"The usual consequence of anesthesia of the trigeminals following 
cranial injury is so-called keratitis neuroparalytica." 

Auditory Nerve. — -The auditory nerve is rarely injured without 
other serious lesions, and since traumatic disturbances of hearing 
may be due to injury to the labyrinth or tympanum also, a diagnosis 
of injury to the nerve trunk must be uncertain. 

The pneumogastric may be divided or contused by bullet or stab 
wounds in the neck. The injury is not necessarily fatal, but may be 
followed by difficulty in respiration and deglutition or by pneumonia. 
When the symptoms point to injury an effort should be made to re- 
pair it. It is reached by the same operation as that for ligation of the 
common carotid. x 

The phrenic when divided gives rise to disturbances of the func- 
tions of the diaphragm, cough, difficult respiration. 

The recurrent laryngeal when divided gives rise to hoarseness and 
aphonia. If injured, an attempt should be made at repair. Laryn- 
geal spasm may require a tracheotomy. 



REPAIR OF MEDIAN NERVE 



361 



Median Nerve— -The median nerve is likely to be divided by stab- 
or gunshot wounds and may be exposed in any part of its course. 

Injury to the median nerve results in impaired flexion of the hand 
and fingers and movements of the thumb. 

To Expose the Median Nerve. — (A) In the middle third of the arm 
(Fig. 282): Place the patient on the back with arms abducted to a 
right angle, the operator standing to the inner side of the arm. 

With the two hands define the biceps muscle. Along the inner 
border of the muscle, following the known line of the nerve (from the 




Fig. 282. — Exposure of the median nerve in the middle third of the arm. B. Biceps. 
M. N. Median nerve. B. A. Brachial artery. {Schwartz.) 



middle of the axilla to the middle of the bend of the elbow) make an 
incision 2 or 3 inches long, dividing the skin and connective 
tissue. Divide the deep fascia over the biceps and open the sheath 
of the muscle. Isolate the border of the muscle and with the retrac- 
tor draw it gently aside. Do not use force or the nerve also will be 
displaced or the musculo-cutaneous may be exposed instead of the 
median. 

Now incise the deep layer of the muscle sheath exactly in the line 
that was occupied by the border of the muscle and the nerve is ex- 
posed lying a little to the inside of the vessels. 

(B) At bend of elbow (see Brachial Artery). 

(C) In the tipper third of the forearm (Fig. 283) : The incision begins 



362 



INJURY AND REPAIR OF NERVES 



a little below the bend of the elbow, is 2 or 3 inches in length, 
and follows the line of the nerve, which lies in the middle line from 
the elbow to the wrist. Divide the skin and ligate the two superficial 
veins. Under the deep fascia define the external border of the pro- 
nator radii teres and over this border incise the aponeurosis and re- 
tract the muscle. 

The nerve is immediately exposed, together with the ulnar artery, 
which crosses beneath it, running obliquely toward the inner border 
of the forearm. 




Med.N. 




Fig. 283. — Exposure of the median nerve Fig. 284. — Exposure of the median nerve 
just below the elbow. The- pronator radii at the wrist. {Schwartz.) 

teres (p. r. t.) drawn inward exposing the 
median nerve (m. n.), the ulnar artery (u. 
art.) being at outer side. {Schwartz.) 

(D) At the wrist (Fig. 284). Make an incision 2 inches in length 
in the middle line, the middle of the incision corresponding to the 
crease of the wrist. Divide first the skin and the fascia and then, very 
carefully, the anterior annular ligament, guarding the synovial sheath 
of the flexor tendons. Retract the lips of the wound, and the nerve 
is exposed, easily distinguishable from the adjacent tendons by its 
fibrillated appearance. 

The Ulnar Nerve. — -The ulnar nerve may be divided anywhere 
along its course, but is more likelv to be contused in the ulnar 



REPAIR OF ULNAR NERVE 



3t>3 



groove. 



There also it may dislocated by forcible flexion of the 
forearm. The loss of function of this nerve results in inability to 
extend the distal phalanges, to adduct the ringers and to flex the little 
finger. Eventually the "claw hand" appears as a result of atrophy 
of the muscles. 

To Expose the Ulnar Nerve. — (A) In the arm: Make an incision 
2 or 3 inches in length along the line of the nerve, which ex- 
tends from the middle of the axilla to the internal condyle. Divide 
the skin and superficial and deep fascia. The brachial artery is about 
a finger's breadth to the outside of the line of incision. Draw the 



M.N 




Fig. 285. — Exposure of the ulnar nerve in the upper third of the arm. M. N. Median 
nerve. B= A. Brachial artery. U. N. Ulnar nerve. Tr. Triceps muscle. {Schwartz.) 

basilic vein to one side. Carefully divide the subjacent tissue be- 
neath which is the ulnar and median nerves and the brachial artery; 
the ulnar nerve is to the inside and in contact with the long head of 
the triceps. (Fig. 285). 

(B) At the elbow (Fig. 286) : Place the patient on the back; abduct 
the arm; flex the forearm at a right angle; stand to the inner side 
of the arm and locate the inner condyle, the olecranon and the in- 
tervening gutter. Along the line of the gutter incise the skin and the 



3 6 4 



INJURY AND REPAIR OF NERVES 




I.C. 

E.C.U. 

U.N. 
Olec. 
Trie. 



Fig. 286. — Exposure of the ulnar nerve at elbow. I. C. Internal condyle. E. C. U 
Extensor carpi ulnaris. U. N. Ulnar nerve. Olec. Olecranon process. Trie. Triceps, 
(Schwartz.) 




Fig. 287. — Exposure of the ulnar nerve at the wrist. U. A. Ulnar artery. U. N. Ulnar 

nerve. (Schwartz.) 
(C) In the lower third of the forearm: Following the line of the nerve, from the internal 
condyle to the radial side of the pisiform, make an incision 2 inches long to the outside 
of the flexor carpi ulnaris, dividing the skin and superficial fascia. Retract inward the 
tendon of this flexor. Carefully incise the deep fascia and the nerve is exposed lying to the 
ulnar side of the ulnar artery. 



REPAIR OF THE MUSCULO-SPIRAL 365 

fascias for 2 or 3 inches, and the nerve will be exposed, accom- 
panied by the posterior ulnar recurrent artery. 

(D) In the wrist (see Fig. 287). 

Musculo-spiral. — The musculo-spiral, more than any other nerve 
of the arm, is subject to injury from stab, contused, or gunshot 
wounds or to fracture of the humerus. Very characteristic, too, are 
the symptoms resulting from its loss of function. The wrist and 
fingers cannot be extended and assume the attitude well known as the 




Fig. 288. — Exposure of the musculo-spiral in its lower third. The supinator longus is exposed 
and the nerve found to its inner side lying upon the brachialis anticus. {Schwartz.) 

"drop wrist." In every fracture of the humerus, the stability of this 
nerve should be tested. The nerve may be explored in any part of 
its course, but is most easily reached at the outer side of the arm just 
above the elbow. 

To Expose the Musculo-spiral. — In the lower third of the arm (Fig. 
288): The arm is abducted, the forearm extended and the hand 
supinated. Stand to the outside of the limb. In the line of the 
nerve, a line drawn along the middle of the external surface, begin- 
ning half-way between the shoulder and elbow and extending to a 
point 3^2 i ncn from the center of the bend of the elbow, make an 



3 66 



INJURY AND REPAIR OF NERVES 



incision 2 or 3 inches in length through the skin and superficial 
fascia. Retract the cephalic vein. Divide the deep fascia along the 
border of the supinator longus and expose the muscle fully. Retract 
it to the outside. At the bottom of the wound is the nerve lying upon 
the brachialis anticus (see page 139, Gunshot Wounds). 




Fig. 2S9. — Exposure of the circumflex nerve. D. Deltoid. 
Triceps. T. Maj. Teres major. C. A. Circumflex artery. 
(Schwartz.) 



T. M. Teres minor. Tr. 
C. N. Circumflex nerve. 



Circumflex. — In addition to such injuries as may be due to stab or 
gunshot wounds, the circumflex is liable to be lacerated in violent 
wrenching or in dislocation of the shoulder-joint. 

The immediate result is loss of power to abduct the arm through 
paralysis of the deltoid. The nerve may be exposed as it winds 
around the humerus just below its head. 

Operation. — The course of the nerve is in a line drawn from the 
inner end of the scapular spine to the point of insertion of the deltoid. 



REPAIR OF THE MUSCULOCUTANEOUS 367 

Place the patient on the sound side, exposing the shoulder well by 
rotating the arm inward a little and placing it in front of the trunk. 

Along the line indicated make an incision 3 or 4 inches long, 
corresponding at its outer end to the acromion process, but an inch 
or two from it. This incision divides the skin and superficial and deep 
fascia and exposes the posterior border of the deltoid. Bring into 
view and draw upward this border of the deltoid. 

Next locate the quadrilateral space, bounded above by the teres 
minor, below by teres major, posteriorly by the long head of the tri- 




Fig. 290. — Exposure of the musculocutaneous nerve in the middle third of arm. The 
biceps (B) drawn outward expose; the nerve (M. Cut. X.) lying to the outside of the median 
nerve (Med. N.) and the brachial artery, Br. Art. (Schwartz.) 



ceps, and anteriorly by the shaft of the humerus. By locating the 
tendons of these muscles define this space in which lie the nerve 
and the posterior circumflex artery (Fig. 289). 

The musculo-cutaneous is exposed in the same manner as the me- 
dian in the upper third of the arm (Fig. 290). 

Anterior Crural. — The division of the anterior crural nerve means, 
among other things, loss of extension of the leg. 

To outline it locate the spine of the pubes and the anterior-superior 
iliac spine, which points are connected by Poupart's ligament; under 



3 68 



INJURY AND REPAIR OF NERVES 



this ligament a finger's breadth outside of its middle point the nerve 
passes (Fig. 291). 

To Expose the Anterior Crural. — Make an incision from this point 
downward in the axis of the thigh, about 3 inches in length, divid- 
ing the skin. 

At the upper end of the wound expose the lower border of Poupart's 
ligament. Immediately below this line, open up the sheath of the 



1 




Fig. 291. — Anterior crural and external cutaneous nerves. (Labey.) 



psoas magnus, pass a grooved director under the sheath, and divide 
it to the same extent as the skin incision. Separating the lips of 
the sheath wound, the nerve is seen lying on the fibers of the muscle 
and is to be distinguished by its whiteness and its subdivisions. 

The Obturator. — If the obturator is divided, there follows loss of 
abduction of the thigh. 

To Expose the Obturator. — Abduct the thigh until the border of the 
adductor longus can be clearly defined, and along this line make an 
incision 4 or 5 inches long, beginning an inch below the fold of the 



INJURY TO THE SCIATIC NERVES 



369 



groin, a little to the outside of the scrotal base. Divide the skin and 
superficial fascia, retracting to the outer side the internal saphenous 
vein, but ligating its cross branches (Fig. 292). Divide the deep 
fascia in the same line. 

Separate the adductor longus from the pectineus by blunt dissec- 
tion. A fairly well-defined gutter indicates the line of separation. 
Retract the two muscles and at the bottom of the upper part of the 
wound you will see the obturator nerve, consisting of a couple of 
flattened cords. Now extend the thigh to relax the abductors and 




Fig. 292. — Exposure of the obturator nerve; separating the adductor longus from 

the pectineus. (Labey.) 



separate more widely the two muscles mentioned and the nerve may 
be completely exposed, one branch lying upon the adductor brevis 
and the other passing under it (Fig. 293). 

Ilio-inguinal and Genito-crural. — These nerves are frequently 
wounded in hernia operations, and may give rise to an obstinate 
neuralgia of the testicle requiring removal of this organ. In such a 
case an effort should first be made to repair the nerve or resect it. 

The Sciatic Nerve. — -The sciatic nerve may be injured in many 
24 



37° 



INJURY AND REPAIR OF NERVES 



ways and from the functional point of view, these injuries are always 
serious. It may mean loss of extension of the thigh and complete 
paralysis of the leg. 

It may be exposed at any part of its course down the back of the 
thigh. 

Exposure in the Middle of the Thigh. — Place the patient face down- 
ward or on the sound side. Along the line of the nerve (a straight 
line extending from a point midway between the ischial tuberosity 
and the great trochanter to the middle of the popliteal space), make 




Fig. 293. — Obturator exposed. (Labey.) 

an incision 3 or 4 inches long, dividing the tissues down to the 
deep fascia. Determine the interspace between the biceps and the 
internal hamstring, and over it divide the deep fascia and separate by 
blunt dissection the muscles of the space. 

Flex the leg so as to relax them. They are then to be retracted 
widely and in the fatty tissues of the interval the nerve is usually eas- 
ily found. 

The External Popliteal, or Peroneal. — This nerve, like others, is 
liable to injury in fractures and wounds. When it is divided, "foot 



REPAIR OF THE PERONEAL 



371 



drop" occurs. The patient cannot walk without stubbing the great 
toe and to prevent this, the whole leg is raised (steppage gait). 
This nerve bears an important relation to the knee-joint and to the 
tendon of the biceps. 

To expose the peroneal behind the head of the fibula place the 
patient face downward or on the sound side. The line of the nerve 
corresponds to the tendon of the biceps, which may be palpated 
along the external border of the popliteal space, or the course of the 
nerve may be indicated by a line drawn from the tuberosity of 
the ischium to the head of the fibula. In this line, beginning at the 
neck of the fibula, make an inci- 
sion upward 3 inches long, divid- | 
ing the structures down to the 
deep fascia. Carefully divide the 
deep fascia over the tendon of 
the biceps and at once there comes 
into view the external popliteal, 
lying to the inner side of the 
tendon resting upon the external 
condyle of the femur above, and 
lower down winding about the 
neck of the fibula and disappear- 
ing in the peroneus longus. 

To Expose the Musculo-cuta- 
neous. — -Place the patient upon 

his back, the knee flexed and rotated inward, and retained by a 
cushion placed under the thigh; in this manner exposing. the ex- 
ternal aspect of the leg. 

The line of the nerve is drawn from the anterior border of the pero- 
neal head to the anterior border of the external malleolus. Along 
this line, in the middle of the leg, make an incision 3 or 4 inches 
in length dividing the structures to the deep fascia. 

Incise the aponeurosis of the peronei muscles, isolate the anterior 
border of the peroneus longus and draw it backward. The muscle 
may be previously relaxed by rotating the foot outward. The nerve 
will be seen resting upon the peroneus brevis (Fig. 294). 

The Anterior Tibial Nerve. — -The anterior tibial nerve is the 




Fig 294. — Musculocutaneous nerve lying 
upon the peroneus brevis. (Labey.) 



372 



INJURY AND REPAIR OF NERVES 



continuation of the external popliteal nerve. The movements 
of flexion of the foot and extension of the toes depend upon this 
nerve. 

To Expose the Anterior Tibial Nerve. — -(A) In the upper third: 
Put the patient in the same position as for the musculo-cutaneous. 

The line of the nerve is drawn from the front of the peroneal head 
to the middle of the anklejoint (Fig. 295). 

In the line of the nerve make an incision beginning three fingers' 
breadth below the articular line of the knee. Divide to the deep 
fascia; next divide that and then patiently search for the intermus- 
cular septum separating the wide tibialis anticus from the narrow 
common extensor. It will aid greatly in the search to seize with a 
forceps each of the lips of the wound of the sheath and retract. 
This will help to develop the line of cleavage. 




Fig. 295. — Lines representing the course (c) of the musculo-cutaneous; 
(ab) Anterior tibial nerves. CLabey.) 

Remember that the tibialis anticus slightly overlaps the common 
extensor, so that the intermuscular space slopes inward and back- 
ward. Retracting the muscles, the nerve will appear as a small 
rounded white cord lying in front of the vessels. 

(B) In the lower third (see Anterior Tibial Artery). 

Posterior Tibial Nerve. — The posterior tibial nerve supplies the 
movements of the extension of the foot and flexion of the toes and 
may be wounded in any part of its course, although in the region 
of the calf it is deeply situated. Behind the internal malleolus 
it is superficial and easily exposed. 

(A) To Expose Upper Third. — -To expose the posterior tibial in 
the region of the calf is difficult (Fig. 296). 

Position. — Place the patient on his back with the thigh in abduction 



REPAIR OF THE POSTERIOR TIBIAL 



373 



and external rotation, the knee flexed, and the foot lying upon its 
external border and held in this position by an assistant. Standing 
to the outside of the limb the operator with this arrangement can 
see quite well the internal surface of the leg. 




Fig. 206. — Exposure of the post, tibial nerve. Gastrocnemius retracted; 
soleus exposed. (Labey.) 




Fig. 297. — Fibers of the soleus divided and retracted, exposing deeply 
situated, the posterior tibial nerve and artery. (Labey.) 



Locate first the sharp internal border of the tibia, and a fingers 
breadth behind it make an incision 4 inches long, beginning at the 



374 INJURY AND REPAIR OF NERVES 

level of the tuberosity. Divide the tissues down to the deep fascia, 
avoiding the internal saphenous vein, which lies close to the tibial 
border. 

Slightly retract the posterior lip, which will include the gastrocne- 
mius, and in this manner the soleus is exposed. Division of the 
soleus is the next step which must be carefully carried out. Divide it 
longitudinally, but further away from the tibia than the original in- 
cision. Cutting in this manner through the fibers of the soleus, the 
yellow aponeurosis covering the nerve and vessels is exposed (Fig. 297). 
It is important to expose this landmark well. Make an opening in it 
an inch and a half from the internal border of the tibia, and beneath 
the opening is the nerve, lying to the outer side of the artery. 

(B) Behind the ankle (see Ligation of Posterior Tibial Artery). 



CHAPTER XXI 

ABSCESS 

An abscess is a circumscribed collection of the liquefied products 
of infective inflammation. 

There are two kinds of abscesses, differing in their etiology, clinical 
history, prognosis, and treatment. All these differences arise pri- 
marily in the nature of the infective agent. The acute abscess is due 
most generally to the activity of certain of the cocci. The chronic 
(or cold) abscess is nearly always due to the Bacillus tuberculosis. 
The chronic abscess may become infected secondarily with the germs 
of acute inflammation, in which instance it takes on the character 
of the acute abscess. 

The content of the acute abscess is pus; that of the chronic abscess, 
though resembling pus, may be merely the liquefied caseated matter 
of the tubercle without any pus cells whatever. An acute abscess 
presents all the cardinal symptoms of inflammation: constitutional 
disturbance, pain, heat, redness, swelling, all in greater or less 
degree, depending on the locality. A chronic abscess may present 
none of these symptoms except swelling, and where swelling is not 
perceptible the abscess is frequently unsuspected. An acute ab- 
scess is of very rapid development — the chronic of quite slow growth, 
as a rule. An acute abscess demands immediate evacuation by 
free incision and drainage. The chronic abscess very often per- 
mits only of aseptic puncture, followed by the injection of deter- 
gent remedies, and aseptic occlusion. 

Each occurs by choice in certain locations. The incision, the 
special dangers and details of treatment depend on the anatomy of 
the parts, so that the more common abscesses require individual 
consideration, and in that connection the general principles that 
underlie the subject may be elaborated. 

The prevention of pus formation should be attempted in all acute 

375 



376 ABSCESS 

infectious inflammations by means of the timely application, in 
favorable localities, of hot antiseptic poultices or prolonged immer- 
sion in hot antiseptic solutions. Even though the treatment fails 
to prevent suppuration, it will at least limit it. Such an antiseptic 
poultice may be made by applying absorbent cotton soaked in hot 
boric acid solution and covering it with oiled silk or gutta-percha. 
In this manner heat and moisture are retained. 

The old flaxseed-meal poultice is more often than not the breeder 
of germs and therefore distinctly non-surgical — a domestic make- 
shift. Some of the " antiphlogistic " glycerinated and sterile clay 
pastes often render an excellent service. 

Treatment. — The evacuation of an abscess is by many regarded 
as a small procedure in minor surgery. It may be nothing more, 
and yet, as Lejars says, in certain cases it is a formidable task 
straining the resources of the most practised. It is an idea too long 
prevalent that there is a minor and a major surgery. There is only 
one kind of good surgery, whether the case is of great or little im- 
portance. It is that which recognizes the indications and meets 
them promptly, giving the patient relief with the least possible 
delay. 

Abscesses have too much been regarded as simple conditions which 
the merest tyro might treat. We all know of patients who have 
died of these operations; of others who have been disabled by the 
failure to perform them, or by their being tardily or improperly 
done. And how often tardily done ! 

But what excuse can one make for delay after pus has definitely 
formed, for any attempt to bring about its absorption is futile. 
Delay merely means that the collection augments, destroys more 
tissues, acquires diverticula without end, which may need to be 
opened up time and time again, or may require months to heal, 
and eventually give rise to irremediable contractions and adhesions. 

It is one of the most important and least varying rules of surgical 
practice that every acute abscess, superficial or deep, must as early 
as possible be incised, emptied, and drained. 

Another point : do not wait for fluctuation, which is so commonly 
the practice. If the suppuration occurs in the deeper structures, 
fluctuation may be delayed. But there are ample indications 



ACUTE ABSCESS 377 

otherwise; the rapid increase of swelling, the radiating pains, 
fever, and subcutaneous edema give sufficient evidence that pus is 
present. 

In certain regions, the thick and brawny skin and fascia is as 
significant as fluctuation itself. On the scalp, for instance, this 
brawny edema is a definite symptom of suppuration. 

The edema is superficial; the suppuration, deep. The two 
processes go together and when the first is present, one may un- 
hesitatingly diagnosticate the second. 

To repeat, when the skin pits on pressure and is only slightly red- 
dened even, the diagnosis is no longer doubtful and one may — one 
should — operate at once. 

The length of the incision is of the greatest importance. Nothing 
is more unsatisfactory than the mere stab, or puncture, of an acute 
abscess. The incision, cutting through the middle, parallel with 
the most important structures, should open up the whole length of 
the cavity. In this manner no pockets are left behind, and, be- 
sides, a long, smooth incision wall in the end leave the least scar. A 
counter-incision may be necessary. 

Once the abscess is opened and the pus has ceased to flow, wipe 
out the cavity with sterile gauze and irrigate with sterile water or 
some antiseptic. If diverticula are found, they too must be freely 
opened up and irrigated. 

Insert a drain. If the abscess was small and the incision made 
early, it is proper to dispense with the drain; but if the suppuration 
is extensive, the best means of preventing large scar formation is to 
employ drainage. 

Observe, then, says Lejars, that the whole therapy of abscesses is 
contained in these two words, " empty" and "drain." 

You do nothing more — there is nothing more to be done — and 
it is sufficient. To attempt to make an abscess cavity aseptic is 
wasted effort. An abscess contains infection of limited virulence 
and when once it is emptied, the living tissues will do the rest, pro- 
vided they are not embarrassed by new germs introduced by the 
operation. 

With this notion in view, then, it must be an absolute rule of 
practice to operate for abscess with clean hands and clean instru- 



378 ABSCESS 






ments in a carefully disinfected field. We may put away for all 
time the old dictum, "If pus is present, antisepsis is useless." 

Disinfect the hands, or what is better, the gloves; boil the instru- 
ments; cleanse the affected area with soap and alcohol and bichloride 
or simply paint with Tr. iodine; then, and then only, are you ready 
to incise the swelling. Wipe out with sterile gauze; use sterile tubes. 
Do not pack with gauze; there is nothing more illogical than tam- 
ponade of an abscess cavity. Cover the wound with sterile gauze 
and absorbent cotton, and bandage firmly so that nothing may enter 
the wound; so that the dressings will not slip or rub. 

The dressings are to be changed daily at first and the tubes every 
second or third day, and are to be shortened as the cavity fills up 
with granulations; are to be dispensed with when pus has ceased 
to form. 

Treatment of Cold Abscess. — The treatment of a cold abscess 
differs from that of an acute abscess in that incision is not the method 
of choice. 

There is always great danger of infection when the abscess cavity 
is opened up and for that reason incision must be done with circum- 
spection — with an absolute asepsis. There is not the urgency present 
in the acute case. 

Puncture is the method of choice. Employ the strictest anti- 
sepsis. Wash with soap and water, but not too vigorously lest the 
abscess wall be ruptured; complete the disinfection with alcohol 
and ether. Employ only such instruments as are carefully sterilized. 
Use a trocar of sufficient size that the grumous fluid will not occlude 
it. Do not puncture the summit of the tumor if the skin is quite 
thin, but select a point where the tissues are sufficiently resistant 
to close when the trocar is withdrawn. At the end of the evacuation 
the fluid may need to be aspirated. It may be discolored by some 
blood from the puncture. 

Injection with some stimulating and antiseptic fluid should follow. 
Ethereal solution of iodoform has the advantage of distending the 
cavity by gas formation and reaching all the diverticula; but it has 
the disadvantage that it is toxic. Inject 5 to 10 c.c. of a 10 per 
cent, solution; leave the trocar in place, closing its orifice with the 
finger. When the cavity becomes distended, remove the finger and 









CHRONIC ABSCESS 379 



the ether spurts out. Let all the gas escape. If one does not 
observe this rule there may be a slough. 

A solution of iodoform in glycerine may be employed; inject 3 to 10 
grams of a 10 per cent, solution, letting the surplus escape. Cam- 
phorated naphthol may be used in the same way. Bismuth paste in 
certain localities serves an excellent purpose. After the injection 
is completed seal the puncture with collodion. Several injections 
may be necessary for a cure. Constitutional treatment is of the 
greatest importance. 

ABSCESSES OF THE SCALP 

These are found in three locations: 

1. Superficial — that is, above the aponeurosis of the occipito- 
frontalis. 

. 2. Subaponeurotic — that is, between aponeurosis and the perios- 
teum. 

3. Subperiosteal — between the periosteum and the bone. 

1. Superficial abscess, due to staphylococci, is quite localized, 
and yet very painful on account of the resistance of the firm tissue. 
The lymph nodes behind the ear and in the back of the neck are 
enlarged and tender. The chief danger is in extension to the deeper 
layers; or the emissary veins may carry infection to the sinuses and 
produce thrombosis or pyemia. Evacuate immediately by free 

, incision, first shaving the scalp in the immediate vicinity of the 
abscess. 

Remembering the manner in which the occipital and temporal 
arteries converge toward the apex, the incision may be managed in 
1 such a way as to run parallel to the small vessels distributed to the 
1 area. 

The cavity must be kept open by a strip of rubber tissue or a small 
drainage-tube. A dressing of gauze, absorbent cotton and bandage 
I complete the treatment. Change the dressing every day at first. 

2. Subaponeurotic abscess is likely to follow wound infection. 
The streptococci follow the areolar tissues that separate the aponeu- 
rosis from the periosteum, and the spread of pus is limited only by 

1 the attachments of the aponeurosis. Septicemia, meningitis, and 



380 ABSCESS 

thrombosis are the actual dangers, and on these accounts immediate 
operation is demanded. 

Make a free incision under antiseptic precautions; that is, after 
shaving and cleansing the part involved. 

Do not attempt irrigations, above all, in these cases, for the fluid 
percolating through the loose areolar tissues spreads the infection. 
Good drainage alone will suffice. The dressings must be changed 
frequently at first and must be firm enough to prevent movement of 
the occipito-frontalis muscle. 

If the abscess develops under the temporal fascia, it will not point 
toward the surface, owing to the extreme density of this fascia, but 
toward the mouth or neck through the ptergo-maxillary fossa. 
Even though there be no fluctuation (usually indeed, none can be 
detected), the diagnosis can, nevertheless, be certainly made from 
the presence of the edema, redness, and pain. Make a vertical in- 
cision an inch or so in front of the ear and with the center about the 
level of the eyebrow. It may be necessary to go through the sub- 
stance of the muscle to the bone. A few small arteries will be divided 
and will require ligation. It may be necessary at the first dressing to 
pack the cavity with gauze to control slight but persistent bleeding. 
Drainage by means of tubes may be employed subsequently. 

3. Subperiosteal abscesses differ from the others in that they 
are likely to be the result of bone inflammation, tubercular or 
syphilitic. The abscesses are limited to the area of one bone as the 
periosteum along the line of the sutures is continuous with the 
dura mater. This furnishes an easy means of entrance into the 
cranial cavity for the infection and in that manner meningitis may 
result. For this reason, these abscesses, of whatever origin, should 
be evacuated at once and appropriate constitutional treatment 
instituted. 

ABSCESS AND FURUNCLE OF THE FACE 

The danger in these conditions is that phlebitis beginning in the 
facial vein may spread to the cavernous sinus, so free is the com- 
munication by numerous branches between these venous channels. 
Especially to be feared are these furuncles beginning on the upper 



ABSCESS OF THE FACE 381 

lip or median parts of the face. They may be fatal in a few days. 
Nearly always the staphylococcus pyogenes is the active causative 
agent and one need not usually be at a loss to trace the mode of 
entrance of the infection. 

Early incision is imperative in all such acute septic processes. 
The best form of local anesthesia in these conditions is by freezing 
; with ethyl chloride spray. Hypodermic injections are best avoided 
here. The incision must be deep to be effective, and in making it 
two factors are to be borne in mind, the resulting scar and injury 
to the branches of the facial nerve. In severe cases even these points 
must be disregarded. Even more certain than free incision is central 
puncture with a fine thermo-cautery, followed by the Bier suction 
treatment. If it is a carbuncle of the diffuse type, accompanied by 
edema of the face and inflammation of the veins, crucial incision with 
curettement must be undertaken. The dressing of gauze may be 
held in place by adhesive strips. 

ABSCESS OF THE NASAL SEPTUM 

Following a blow upon the nose, bleeding ensues and, two or three 
days later, obstruction. Looking into the child's nasal fossae, they 
are seen to be filled with a bright red, tender, fluctuating swelling, 
over the cartilaginous portion of the septum. The whole nose 
becomes hot, swollen, and painful. 

The treatment is evacuation by a free incision of the mucous 
, membrane over the septum at the point of greatest fluctuation. 

To operate, apply a 4 per cent, solution of cocaine to the mucous 
membrane, and after waiting a minute or two, make an incision 
along the septal wall from above downward and forward with a 
! slender, sharp bistoury. Douche the nasal fossa frequently with a 
mild, alkaline antiseptic. Recovery usually follows within a week, 
although in the neglected cases, necrosis of the cartilage may occur. 

I 

ABSCESS OF THE EYELIDS 

The loose connective tissues of the eyelids favor exudation and 
, edema. An abscess occurring here is usually due either to trauma- 



382 ABSCESS 

tism or to septic infection entering from the face or scalp or to 
periostitis of the margin of the orbit. Early treatment of con- 
tusions may prevent not only the unsightly discoloration (" black 
eye"), but also a later abscess. 

To prevent discolor ations apply cooling or evaporating lotions or 
wring a gauze compress out of ice-water and apply to the lid, re- 
newing the compress every two or three minutes. Do not allow the 
compress to cover the nose, else acute coryza may result. Apply 
in this manner for an hour and repeat every second or third hour for 
twenty-four hours. A solution of arnica (2 oz.), in water (1 pt.), 

may be applied, or 

Ammonii chloride, 1 

Alcohol, 1 

Aquae, 10 

If discoloration appears, apply flannel cloths wrung out of hot water, 
for an hour at a time, three or four times daily, and follow with gentle 
massage for five to ten minutes. Before applying the heat it is 
better to smear the lid with vaseline. Ointment of yellow oxide of 
mercury is excellent to use with massage. If an abscess appears 
make an incision parallel with the muscle fibers. Apply antiseptic, 
absorbent dressings. 

ABSCESS OF THE LACHRYMAL GLAND 

Abscess of the lachrymal gland is rare, yet doubtless is often over- 
looked. It is seen in infancy, usually traceable to some of the in- 
fectious diseases. The abscess breaks into the superior cul-de-sac 
and recovery follows. 

ABSCESS OF THE EXTERNAL AUDITORY MEATUS 

Abscess of the external meatus is extremely painful and alarm- 
ing, but in fact not particularly dangerous. The meatus is closed 
by the swelling, but a stab with the point of the knife or, if it is more 
deeply situated, an incision in the direction of the long axis of the 
meatus, will cause a speedy disappearance of the symptoms. Gentle 



PAROTID ABSCESS 383 

10 douching with an antiseptic solution, and, after drying, occlusion 
■ with absorbent cotton, will soon complete the cure. 

ABSCESS OF THE PAROTID GLAND 

An inflammation begins in the parotid gland, the result of local 
1 infection or secondary to an abdominal disease or injury (most fre- 
quently involving the pancreas, perhaps), and nearly always sup- 
ipuration follows. The severe forms are dangerous; happily, how- 
, ever, the pus, even if left to take its own course, works its way to 
the surface or points at the phraynx. It may burrow down to the 
anterior mediastinum. The special dangers are meningitis, septic 
poisoning, and thrombosis. When the swelling is great, pressure 
interferes with the venous current and, as a result, cerebral con- 
gestion, headache, and finally delirium ensue. The pus may open 
j into the middle ear and infection by that route reaches the brain. 
; Suppuration of the temporo-maxillary articulation may follow. 
j Treatment. — If, when the swelling first appears, a probe be passed 
into Stenson's duct and the gland be pressed from the outside, a few 
drops of pus may be squeezed out and this may serve to head off a 
general suppuration. If the entire gland becomes involved, hot 
antiseptic poultices should be applied to hasten the localization of 
\ the pus. As soon as redness and edema indicate the most probable 
situation of the pus, an effort must be made to evacuate it. Several 
important structures are to be avoided; Stenson's duct (a fistula 
is likely to follow its division), the facial nerve, the carotid arteries, 
the temporo-maxillary vein and other vessels of lesser importance 
may be wounded. 

If the anterior part of the gland is involved, the incision is made 

' parallel with and below Stenson's duct. The skin and fascia are 

* divided and retracted and an effort is made to burrow into the depths 

of the gland with a probe or grooved director. The pus follows the 

j connective-tissue laminae instead of the lobules of the gland, and it is 

I better, if possible, to avoid dividing the glandular substance. If 

the posterior and lower part of the gland is involved, the incision should 

be vertical, with its center a little above and anterior to the angle of 

j the jaw. The temporo-maxillary vein will be seen, running parallel 

I 



384 



ABSCESS 



to the incision near the surface of the gland. A drainage-tube must 
be left in the deeper abscesses. 

DENTAL ABSCESS 

These painful affections are not to be neglected,. for they may 
lift up the periosteum and result in necrosis of the jaw. Left to it- 
self, the abscess may point in the mouth, less frequently on the face. 
It begins in the alveolar process from infection from a carious 
tooth. It makes its appearance at the junction of the cheek and 
the gum. Inspection and palpation make the diagnosis. A cotton 



M.H- 





Pig. 298. — Dental abscess. 
(Veau.) 



Fig. 299. — Submaxillary abscess 
in contact with inner surface of the 
inferior maxilla. M. H. t Mylohyoid 
muscle. P., Platysma myoides. 
GLs.M., Submaxillary gland. 
(Veau.) 



tampon soaked in 2 per cent, cocaine solution is laid on the gum for 
five or ten minutes, but analgesia will not be complete. Lift the 
cheek away from the gum as far as possible, and with a sharp- 
pointed bistoury, wrapped to within a half-inch of the point, make 
a horizontal incision and cut down to the bone. There is nothing 
to fear and without getting deep one may fail. The patient may 
resist further efforts or the field may be obscured by blood (Fig. 298). 
Order an antiseptic mouth-wash to be used every half-hour at 
first, and the pain will rapidly disappear. In more extensive sub- 
periosteal abscess of the jaws, the same principle of procedure should 
be carried out. 



INCISION OF SUBMAXILLARY ABSCESS 



38S 



SUBMAXILLARY ABSCESS 

Do not await fluctuation in acute inflammations in this locality. 
The pain, augmented by pressure, the brawny edema and diffuse 
redness are sufficient to demonstrate the presence of pus. The 
pus is not always easy to find, for it is deep, often subperiosteal 
and in contact with the internal surface of the jaw, and is generally 
due, in fact, to dental infection (Fig. 299). 




Fig. 300. — Incision of submaxillary abscess. Dotted line represents the 
facial artery. (Veau.) 



Local anesthesia is often sufficient. Locate the angle of the jaw. 
This is often difficult on account of the edema. A finger's breadth 
below, and following the body of the jaw, make a curved incision 
(Fig. 300) with slight downward convexity about 3 inches in 
length. Remember the point at which the facial artery crosses the 
body of the jaw, just in front of the masseter. Do not cut deeper 
than the skin, for this is dangerous ground. Now dissect with 
forceps and grooved director the subjacent tissues, making haste 
25 



3 86 



ABSCESS 



slowly and renewing from time to time the analgesia or injections 
as the patient complains of pain. 

Carry the dissection upward and inward toward the inner surface 
of the jaw, and with patience the abscess will be located. As it is 
approached, the tissues will be found more and more edematous 
and filled with serum. Having once cut into it, enlarge the opening, 
always too small, by introducing and opening an artery forceps. 
Irrigate with normal salt solution, insert one or two small drains, 
dress with antiseptic gauze and absorbent cotton, and renew daily. 




// ff 



Fig. 301. — Phlegmon of the floor of the Fig. 302. — Incision for phlegmon of 
mouth. The tongue is pushed to the oppo- floor of mouth. (Veau.) 

site side and the spread downward of the 
purulent collection opposed by the mylo- 
hyoid muscle. GSL. t sublingual gland. AL, 
lingual artery. CW t salivary duct. GGL, 
genio-hyo-glossus. GY t genio-hyoid. MY, 
hyo-glossus. D, diagastric. (Veau.) 

The temperature will fall rapidly. After five or six days the drain- 
age may be diminshed and after ten days entirely removed. 

ABSCESS OF THE FLOOR OF THE MOUTH 

(Ludwig's Angina) 

This is a very grave, usually fatal condition, originating in strepto- 
coccic infection through the mucous membrane of the floor of the 
mouth. It more frequently occurs in adults, though childhood is 



ludwig's angina 387 

not exempt. Its tendency is to extend into the neck, following 
the cellular planes, and if the patient does not die early from septi- 
cemia, gangrene may occur. In a very few hours" after the infection 
begins, the floor of the mouth becomes brawny,' the tongue is thrust 
up against the hard palate, and breathing and swallowing markedly 
interfered with. If anything is to do good, it must be done at once 
(Fig. 301). 

Try the antistreptococcic serum — if it does no good, it will at 
least do no harm. In the meantime, operate. Usually a general 
anesthesia is indispensable. Make an incision a finger's breadth 
below the body of the jaw about 3 inches long so that it reaches 
beyond the median line (Fig. 302). If both sides are equally in- 



Fig. 303. — Deep incision for phlegmon in floor of mouth. G.s.M., submaxillary gland 
M.H., niylo-hyoid muscle. D, digastric muscle. (Veau.) 

volved, make a bilateral incision. One may perhaps recognize the 
platysma, but the anterior belly of the digastric must be demon- 
strated and divided. Next expose the mylo-hyoid and divide com- 
pletely (Fig. 303). Having now reached the sublingual space, you 
may find merely a serous exudate, characteristic of this form of 
infective inflammation. Do not stop until the mucous membrane 
of the mouth has been demonstrated, for otherwise one may mis- 
take the submaxillary for the sublingual gland and not go deep 
enough. 

Douche thoroughly with peroxide, place two or three large drain- 
age-tubes, pack with gauze saturated with peroxide, and apply 
absorbent cotton. Renew the dressings and flushing three or four 
times daily and the serum injections as well. Possibly the patient 
will go on rapidly to death from septicemia. He is almost certain 



388 ABSCESS 

to do so without the operation. The drainage may be diminished 
toward the tenth day. Several weeks will be required for a cure. 

ABSCESSES OF THE TONGUE 

Abscesses of the tongue do not often occur, but when they do, 
may give rise to urgent conditions. They may develop suddenly 
with much pain, which may be variously reflected — to the ear, for 
example. 

The tongue may be so swollen as to fill the mouth and severely 
disturb respiration. The location of the abscess is to be determined 
by palpation. If it is at the base of the tongue and pointing to- 
ward the surface, is it to be evacuated by a median longitudinal in- 
cision from behind forward and deep enough to reach the pus. 
There is no danger of wounding important structures if the incision 
follows the middle line. Leave a strip of gauze in the wound for 
drainage. Prescribe frequent antiseptic mouth-washes. If the 
abscess lies under the tongue and points downward, the incision 
must be made along the floor of the mouth, if the mouth can be 
sufficiently opened and fluctuation detected. The ranine artery 
may be wounded. If the mouth cannot be opened it is best to 
operate from the outside, making a median vertical incision from 
the symphysis of the chin down, getting between the two genio- 
hyo-glossi muscles and following this crevice up to the under surface 
of the tongue. Drainage-tube, antiseptic absorbent dressing. 

TONSILLAR ABSCESS 

" Quinsy' ' is an actue suppuration in the tonsil or around the 
tonsil following acute infection of the gland. 

Often the suppuration occurs only on one side, though both 
tonsils are inflamed. At any rate the two tonsils do not suppurate 
simultaneously. 

The temperature is high, the pain extreme, there is difficulty in 
swallowing and perhaps in breathing. There may be edema of the 
glottis. Often there is difficulty in opening the jaws. After the 
abscess is well formed, the soft palate is edematous and swollen. 



TONSILLAR ABSCESS 



389 



Pus. begins to form about the third day after the attack. Pre- 
vious to this an effort should be made to abort the abscess. Give 
calomel in small frequent doses and follow with a saline purge, 
and in the meantime administer full doses of sodium salicylate. 
Phenacetine, 2 or 3 grains frequently, will make the patient 
more comfortable. Paint the tonsils and pharynx with argyrol 
once a day and use the peroxide spray (50 per cent, solution) every 
two or three hours. Apply hot anti- 
septic fomentations or poultices exter- 
nally. 

If these measures fail to relieve the 
symptoms after the third day, it is 
almost certain that pus has formed, 
even though fluctuation cannot be 
felt, and it is best to make an incision, 
but this must be free. 

The operation is sometimes difficult. 
A general anesthesia will be necessary 
if the jaws are locked. Open the 
mouth wide. A mouth gag is often 
necessary. Depress the tongue as 
much as possible. Swab the tonsil 
with a 10 per cent, solution of co- 
caine. With a sharp pointed bistoury bie. (Veau.) 
(wrapped), make an incision in the 

soft palate just external to, and parallel with, the anterior pillars 
and extending as low down as possible. If the pus flows freely, some 
of it may be swallowed, to prevent which bend the head down. 
Continue the spray and antiseptic mouth-washes for a few 
days. Whether pus is located or not, free incision gives great 
relief (Fig. 304). 

RETROPHARYNGEAL ABSCESS 




Fig. 304. — Tonsillar abscess. In- 
cision should extend as low as possi- 



These conditions are treacherous and dangerous because (most 
frequent in infants) they may be overlooked and, bursting into the 
pharynx, may produce suffocation. 

The pharynx is separated from the muscles covering the anterior 



39° 



ABSCESS 



surface of the bodies of the cervical vertebrae by a loose connective 
tissue. One or two lymphatic glands lie in front of the bodies of the 
upper two cervical vertebrae on either side of the middle line. These 
receive lymph (and infection) from the nasal cavities and their 
accessory sinuses, the naso-pharynx, the Eustachian tube, the tym- 
panum, and from the tissues lying on the bodies of the adjacent 
vertebrae. Septic conditions existing in any of these localities may 
be the source of the inflammation of these lymph glands, which may 
end in suppuration. These glands empty by several chains of lymph 
vessels into the deep cervical glands. 

The suppuration begins on one side usually, but rapidly spreads 
toward the middle line, where the tissues are loosest. The abscess 
may be behind the palate; it may be opposite the larynx; in either 
case almost out of sight. Usually, however, it is seated in the pos- 
terior wall of the pharynx, opposite the oral cavity. When situated 
there, it gives rise to fewest symptoms, and for that reason its de- 
velopment is insidious, and in the infant unsuspected. The con- 
stitutional disturbance may be slight. 

Obstructed breathing and hoarseness and a feeling of tightness 
in the throat may first suggest the difficulty. Inspection and 
palpation, always necessary, are not always easy and, in the case 
of infants, sometimes dangerous. Still, only by touch, with the 
finger in the mouth, can the exact condition be determined. To 
prevent asphyxia or syncope, the main thing is to be rapid in the 
examination. To facilitate this, the child must be prepared. 

It is seated on the assistant's lap with its face turned to the light, 
its arms and body encircled by a towel, its legs held firmly between 
the assistant's knees. Its mouth is forced open by pressing the 
cheeks between the teeth. The finger is passed to the back of the 
tongue and rapidly palpates the walls of the pharynx. It is not 
difficult to determine the point of greatest swelling. 

Operation. — i. Have already prepared a sharp-pointed bistoury 
wrapped with cotton close up to the point. The index finger in 
the mouth holds the tongue down and the bistoury is passed along 
the finger and plunged into the abscess in the middle line, that no 
blood vessels may be injured. This puncture is prolonged into an 
incision from above downward at least an inch; in fact, as low as 



RETROPHARYNGEAL ABSCESS 



391 



possible, that chances of a recurrence may be diminished. The 
patient is immediately inclined forward in order that the pus may 
pour out of the mouth (Fig. 305). 

If syncope or spasm of the larynx occurs, do not lose your head, 
but proceed hastily to revive the patient by the ordinary means. 
Lower the patient's head, pull out the tongue, and employ artificial 
respiration. 




Fig. 305. — Retropharyngeal abscess. (Veau.) 



As after-treatment, direct frequent irrigations or gargling with 
sterilized water. A peroxide spray may be used with good effect. 
Recovery occurs within a few days. 

If the abscess recurs, or in the first place is situated too far down 
for oral puncture (which may sometimes be done by passing a 
curved director over the base of the tongue and then downward to 
the top of the abscess), or the jaws are locked, it will have to be 
reached from the side of the neck, an operation much more difficult 
in every way. 

Operation. — 2. Turn the patient slightly to one side, resting the 
neck upon a cushion to make its lateral aspect prominent; the sterno- 



392 



ABSCESS 



mastoid is the guide. Make an incision about 2 inches in length 
along the posterior border of the sterno-cleido-mastoid, which is 
exposed after the skin and fascia are divided. Ligate the veins; 
avoid the superficial cervical nerves; pull the sterno-cleido-mastoid 
forward and locate the scalenus anticus. Stick to the scalenus 
anticus, follow its anterior surface inward, displacing forward by 
careful dissection with grooved director, the common sheath of the 
great vessels and pneumogastric. The connective tissues are rather 
loose; the dissection is not difficult. Be on the watch for the spinal 
accessory nerve, which lies on the deep surface of the sterno-mastoid. 
Working inward in this manner reach the outer border of the longus 
colli which lies in the same plane as the scalenus anticus, and upon 
which lies the pharynx and the abscess. After opening and empty- 
ing, a drain must be left. Employ the usual dressings and after- 
treatment. Sometimes the abscess lies further forward and it will 
be necessary to go in front of the sterno-cleido-mastoid. After the 
skin and fascia are divided, the finger in the wound will be able to 
locate fluctuation and that will be the best guide in the subsequent 
dissection. It may be necessary to ligate several small veins. Re- 
tract the anterior border of the sterno-mastoid and with it the 
sheath of the common carotid, the internal jugular and pneumo- 
gastric; draw toward the thyroid, the larynx and trachea. The 
fascias are divided by blunt dissection until the abscess cavity is 
opened. 

ABSCESS OF THE GLANDS OF THE NECK 

Acute suppuration of the lymph glands of the neck is quite fre- 
quent and originates in infective disorders of the areas drained by 
the glands. 

In treating these conditions, the source of the infection must not 
be overlooked. It is not always advisable to operate immediately, 
even though suppuration is believed to be present, unless, of course, 
the infection shows a tendency to become general. 

In the ordinary case, the pus may be very deeply located or out- 
side the capsule of the gland. It is better under these circumstances 
to apply hot antiseptic poultices for twenty-four to forty-eight 
hours. The whole gland then becomes softened, the pus is easily 



MAMMARY ABSCESS 393 

evacuated and healing occurs rapidly; whereas a non-suppurating 
gland cut into may remain enlarged and indurated. Free incision 
is always out of the question as the many important structures of 
the neck have to be borne in mind. Use local anesthesia. In mak- 
ing the incision it is usually best to follow the posterior border of 
the sterno-mastoid. Make an incision about 2 inches in length. 
When the muscle is reached, draw it forward with a retractor and 
with a grooved director search for the pus cavity; drain; use absorbent 
dressings. 

CHRONIC SUPPURATION OF THE CERVICAL GLANDS 

There are various clinical manifestations of the tubercular proc- 
esses, each of which demands a somewhat different treatment. It is 
assumed that the pus, gradually accumulating, has burst through 
the fascia and has begun to bulge the skin. 

It is best to operate at once. The most careful asepsis should be 
maintained. The pus is evacuated by free incision and the abscess 
cavity wiped out with iodoform gauze. A 10 per cent, solution of 
iodoform emulsion with glycerine is poured into the cavity (2 or 
3 drams are sufficient) and the wound sutured and treated as 
an aseptic w r ound, provided there is no evidence of secondary 
infection. 

ABSCESS OF THE BREAST 

Abscess of the breast may be either parenchymatous, originating 
1 in the substance of the gland; or submammary, originating in the 
areolar tissues separating the gland from the pectoralis major. 

In either case infection nearly always begins at the nipple and 
follows the lymph vessels downward. The first form is usually due 
to staphylococcic infection, the second to streptococcic. These 
conditions are preventable in the greater number of cases and for 
that reason the nipple should be given special care both before 
I confinement and during the first weeks of lactation. 

Even when the breast becomes " caked" and tender and there is a 

little fever, antisepsis at the nipple and hot antiseptic poultices to 

l the breast may prevent abscess formation. Continued rise in tern- 



394 



ABSCESS 



perature, slight chills, edema and pain, more or less localized, indi- 
cate the formation of pus, and immediate operation is necessary. 
A general anesthesia is best for thoroughness, though the work may 
be done under local anesthesia. 

Under rigid asepsis, proceed to open up the cavity, and always 
remember, the earlier the better. An incision an inch or so long 
should begin near the nipple and radiate from it, as the spoke from 
the hub of a wheel. In this manner the least possible number of 
the milk ducts and vessels are divided (Fig. 306). 




Fig. 306. — Abscess of the breast: incision. (JLejars.) 

The first incision goes through the skin and fascia and then the 
abscess cavity is sought for by blunt dissection with a grooved 
director. Still there is nothing to fear in cutting boldly down to the 
abscess. Explore the cavity thoroughly for there may be pockets 
leading off from the main cavity. Do not neglect this point. If it 
extends deep, make a counter-opening at the base, being guided by 
the director introduced through the first opening (Fig. 307). Push 
ing a forceps through the channel, it seizes a drainage-tube which is 
drawn into place as the forceps is withdrawn. Dress with anti 
septic gauze, which should be changed twice daily at first, car 
being taken not to disturb the drainage-tube. 

If the temperature rises again after the second or third day, you 



: 



« 



AXILLARY ABSCESS 



395 



will have to re-explore. A new abscess is in process of formation. 
After five or six days replace the first drainage-tube with a smaller 
one. The drainage-tube can be entirely dispensed with after ten 
days or two weeks. 

The submammary abscess develops without edema or redness 
because it underlies the whole breast. The condition can scarcely 
be mistaken, for the marked elevation of the whole breast, along with 
the constitutional symptoms point to the nature of the trouble. 
Make a curved incision following the base of the breast at its lowest 




Fig. 307. — Abscess of the breast. Manner of making counter-opening. D, grooved di- 
rector; P, its point; B, bistoury cutting down on to the point of director. (Lejars.) 

part, dividing the skin and fascia. With a grooved director, dissect 
through the areolar tissues between the gland and the chest wall, 
working toward the center of the breast. These deep tissues are 
likely to be infiltrated. In this manner the pus is evacuated and 
the subsequent treatment will be practically the same as that 
prescribed for the preceding form. 



AXILLARY ABSCESS 

Three chains of lymphatic glands are found in the axillary space. 
One lies along the anterior fold of the axilla and drains the anterior 



396 



ABSCESS 



thoracic region; one lies on the posterior axillary wall and drains the 
posterior thoracic region; one lies alongside and externally is con- 
nected with the axillary vessels and drains the upper extremity. 
Axillary abscess usually results from inflammation of one or the other 
of these chains of glands, the infective agent having been carried 
to them from a distant point, such as the breast or hand, by the 
lymph vessels. 

The inflammation spreads from the glands to the adjacent areolar 
tissue and pus formation follows. Abscess may also form by exten- 
sion of pus formation from the base of the neck. 



; 




Fig. 308. — Cross section showing relations of axillary abscess. G. F. Pect. major. 
P.P. Pect. minor. G. D. Latiss, dorsi. S.SC. Subscapulars. G. D. Serratus magnus. 
(Veau.) 



The most frequent sources of infection, probably, are the breast 
and the sebaceous glands in the skin of the armpit. Abrasions and 
small boils in this locality must be treated with circumspection, lest 
they terminate finally in axillary abscess. The ordinary symptoms 
of inflammation and pus formation, added to the painful abduction 
of the arm, indicate the nature of the trouble. 

It is imperative to evacuate the pus promptly for the reason that 
it may burrow in various directions, usually upward toward the neck. 
The axillary vessels may be eroded. 

The incision will depend upon the location of the pus — that is to 






AXILLARY ABSCESS 



397 



say, whether it lies under the pectoralis major or in the loose areolar 
tissues of the center of the space. Acute abscess more often lies 
in the first locality (Fig. 308) ; tubercular abscess in the latter. 

(a) Acute Abscess (Fig. 309). — General anesthesia; place the 
patient on his back; abduct the arm as much as possible; and locate 
the border of the pectoralis major. Make an incision 3 inches 
in length along this line, cutting toward the thorax; expose the 
muscle border well; dissect along the under surface of the pectoralis 
major with the grooved director. In this manner you keep in front 
of the great vessels and nerves and will feel secure. When the pus 
once flows, enlarge the opening, and insert drainage-tubes. 




Fig. 309. — Incision for acute axillary abscess. The blunt dissection should follow 
the anterior axillary wall. (Veau.) 

To avoid the axillary structures, you must keep these two points 
in mind: (1) Make the opening large enough to see what you are 
doing — a blind stab in this region is exceedingly dangerous; (2) 
stick to the pectoralis major — the pus is in contact with its deep 
surface. Wash out the cavity and place two drains; use a gauze and 
absorbent cotton dressing daily for a week, after which jremove the 
tubes, though the external opening must not be allowed to close until 
the cavity is eliminated. 

(b) Chronic Abscess. — Incision. Begin in the middle of the floor 
of the space and follow the middle line away from the arm toward 



398 ABSCESS 

the chest. In this direction alone is safety. In front are the long 
thoracic vessels; behind are the subscapular vessels; to the outside 
are the main axillary vessels and branches of the brachial plexus. 
The skin incision may occasionally divide a small artery, which will 
at first give some concern. It is best to divide the connective tissues 
layer by layer in the original line of incision. There is no danger 
if you keep in this line. Otherwise, the pus may be reached by 
Hilton's method. After the skin and fascia are divided, a dressing 
forceps is pushed up into the abscess cavity and the bladeso pened. 
Put in a drainage-tube; use absorbent dressings; maintain a careful 
asepsis throughout the process of repair. 

PALMAR ABSCESS 

These are always serious conditions, not alone on account of sepsis, 
but because the hand may be left permanently crippled or useless as 
a result of the destruction of tissue and inflammatory adhesions. 

Immediate evacuation of pus is imperative. If the pus is limited 
to the connective tissues of the palm, has not reached the tendon 
sheaths, the incision should be made over, and parallel with, the 
interosseous space in the region of the greatest swelling. 

If the tendon sheaths are involved, the incision should be made in 
the long axis of the metacarpal bone (see Phlegmon, page 424). 
Whether the condition is a diffuse inflammation (phlegmon) or an 
abscess will be determined by the history of the case. 

In the case of abscess, make a longitudinal incision. The palmar 
arches are chiefly to be considered. Begin the incision just below a 
line drawn across the palm from the web of the thumb. Beginning 
nearer the wrist, the superficial palmar arch or the deep arch as well 
may be divided. Cut toward the finger, making the incision suffi- 
ciently deep to go quite through the palmar fascia. Insert a drain- 
age-tube. Use antiseptic dressings, changing the dressings daily. 
(See also Phlegmons.) 

POPLITEAL ABSCESS 

Situated in the hollow back of the knee-joint in the superficial 
fascia are a few lymph glands which may suppurate following an in- 



POPLITEAL ABSCESS 399 

fective process in the foot or leg. Situated still deeper beneath the 
deep fascia are other glands which may similarly suppurate. 

These may be described, then, as superficial abscess and deep 
abscess of the popliteal space. 

The superficial abscess may be opened simply by a vertical in- 
cision over the point of greatest swelling. There are no important 
structures likely to be wounded by a superficial incision. 

It is quite different with a deep abscess. The situation of a number 
of important structures must be borne in mind. In the center of 
the lower half of the space lies the short saphenous vein; to the 
outer side lies the external popliteal nerve, and running vertically 
through the center of the space, and deeply located, are the popliteal 
vessels and internal popliteal nerve. The space is roofed over by 
the dense popliteal fascia which is the chief factor in determining the 
direction in which the suppuration extends; thus the pus is more 
likely to point up in the thigh or down in the leg than in the integu- 
ments of the space. 

A popliteal abscess may likewise be the result of the extension of 
a suppurative process in the thigh. These abscesses must be opened 
without delay for the reason that the joint may become involved, the 
vessels may slough, and there may be destruction of tissue. There 
may be permanent flexion of the leg due to scar tissue. 

Before opening a popliteal abscess the diagnosis must be con- 
firmed. It has happened more than once that a popliteal aneurism 
has been mistaken for an abscess and incised, a mistake serious indeed 
for both patient and operator. 

Acute inflammation of the bursae must not be mistaken for ab- 
scess. These bursae are found in the boundaries of the space, 
separating the tendons from the protuberances of the femur, tibia, 
and fibula. 

Operation. — Either general or local anesthesia may be used. Make 
a vertical incision in the center of the space, dividing the skin, the 
superficial fascia, and the deep fascia successively. With the grooved 
director separate the fatty tissues filling the space; keep in the line 
of the original incision. The pus will usually be located before the 
depth of the vessels has been reached. Enlarge the opening in the 
connective tissues, irrigate, search for diverticula, insert a drainage- 



400 ABSCESS 

tube and pack lightly around the tube with aseptic gauze. Apply 
absorbent dressings and extend the leg on a posterior splint. This 
extension must be maintained until the healing is complete to prevent || 
flexion. 



PLANTAR ABSCESS 

The deep fascia of the sole of the foot is especially developed. It 
extends as a broad, dense band, from one end of the plantar arch to 
the other, from the os calcis to the base of the metatarsal bones. 
It is a broad band divided into three portions: outer, middle, and 
inner. The central portion alone is of much surgical importance. 
Its anterior extremity is broken up into five slips, and each slip 
branches and forms an arch for a flexor tendon. 

The result of this arrangement is that here is a closed compartment 
between the fascia and the bones of the foot which is occupied by 
the muscles of the middle foot. Following an infection, pus form- 
ing in this compartment finds great difficulty in escaping. It 
burrows between the metatarsal bones and makes its appearance 
on the dorsum of the foot, follows the flexor tendons backward to 
the inner ankle, or may escape through the small aperture for the 
arteries into the subcutaneous fascia. 

On account of the denseness of the fascia, the pain in plantar ab- 
scess is extreme, and for relief of this pain and to prevent destruc- 
tion of tissue, an early incision is imperative. The incision should 
be made over the most prominent part of the swelling, its direction 
corresponding to the long axis of the foot. 

The skin is divided and then the thick fatty tissues, until the white 
and firm plantar fascia is reached. After the fascia is divided, 
the dissection is completed with a grooved director until the pus 
cavity is located. In this manner no important structures are 
wounded. Wash out the cavity and insert a small drainage-tube. 
It is important that the cavity heal from the bottom. 

ISCHIO-RECTAL ABSCESS 

The ischio-rectal fossa is a wedge-shaped cavity, lying on either 
side of the rectum, between it and the pelvic wall. Its base is 



ISCHIO-RECTAL ABSCESS 401 

covered by the integument and its sharp edge is directed upward 
and corresponds to a line drawn from the pubes backward to the 
spine of the ischium — the line of attachment of the levator ani 
muscle, the "white line" of the pelvic fascia. The levator ani mus- 
cle forms its inner boundary. The obturator fascia covering the 
bony pelvic wall forms its outer boundary. 

The fossa is rilled with fatty tissue which seems to form a packing 
and support for the rectum, but which at the same time forms a 
site of "lowered resistance" to infective agents. 

These infective agents gain access to the fatty tissues of the fossa 
through ulcerations or abrasions of the rectal mucous membrane or 
from similar conditions in the integument around the anal orifice. 
For the most part the bacteria follow the lymphatics which have 
their origin in these localities and which follow the branches of the 
inferior hemorrhoidal vessels through the fossa. The abscess may 
be secondary to prostatic abscess. 

The symptoms of acute abscess here are the ordinary constitutional 
symptoms in marked degree, accompanied by intense throbbing 
pain in the region of the anus. The skin becomes brawny and 
indurated but no fluctuation appears in many cases. 

The symptoms of chronic abscess differ only in degree, and are 
often so slight as to be entirely overlooked. Abscess of any kind in 
this locality, when diagnosed, should be evacuated without delay. 
If let alone it will eventually open the rectum or through the skin 
if the patient should survive the general sepsis. But spontaneous 
evacuation is in every way to be avoided, if possible. A fistula is 
the inevitable sequel if the case is left to nature. 

This fistula, opening into the bowel whether the abscess formed 
near the roof of the fossa or near the floor, is very likely to be just 
above the external sphincter. There the bowel wall is thinnest, 
and the f ascias of the levator ani act as an inclined plane along which 
the pus moves toward that part of the bowel. 

The examining finger in the rectum in the case of abscess will 
nearly always detect the threatened opening there and confirm the 
diagnosis. 

Operation. — General anesthesia; lithotomy position; antisepsis. 

The incision (Fig. 311), 4 or 5 inches in length, is made from 
26 



402 



ABSCESS 



before backward and inclined a little outward midway between the 
ischial tuberosity and the rectum. Remember that cutting too 
near the middle line, you may wound the rectum; too near the pelvic 
wall, you may wound the internal pudic vessels. Some small 
hemorrhage will follow the skin incision. It may be necessary to 
cut deeper along the same line and you may wound some of the 
branches of the inferior hemorrhoidal arteries, but that is not a seri- 
ous matter. 

With a little patience, in this manner the pus is reached and it 
pours out, extremely fetid and often mixed with shreds of con- 
nective tissue. 




Fig. 311. — Ischiorectal abscess. Incision. (Veau.) 

Enlarge the wound so that it may be inspected and explore it 
with the finger. Irrigate vigorously. Being assured that all the 
minor cavities are opened up, introduce a large drainage-tube and 
pack around it with gauze. The dressing must be renewed daily 
at first. The tubes can be gradually withdrawn. 

It is absolutely necessary that the wound heal by granulation from 
the bottom and this may be a matter of weeks or even months. Of 
this the patient should always be forewarned. During this time 
the dressings must be carried out methodically. Often following 
incision and drainage there is a tendency to relapse because the 
primary focus of suppuration in the prostate has not been recog- 
nized and relieved. 

If a small opening is exposed high up in the cavity, through which 
pus drains, it indicates a peri-rectal abscess above the levator ani, 



PERI-ANAL .ABSCESS 403 

dangerous because it may become a general pelvic cellulitis or 
peritonitis. Enlarge the opening by the introduction of a dressing 
forceps, irrigate and drain. 

These peri-rectal abscesses not involving the ischio-rectal fossa are 
difficult to diagnosticate, but when once determined they must be 
opened in the manner already indicated. 

Again, the ischio-rectal abscess may have, unfortunately, already 
opened through the rectal wall. Make the skin incision as before, 
and then an additional step is necessary. Push a grooved director 
up through the abscess cavity and through the rectal opening and 
then, following along the grooved director, cut through the entire 
thickness of the rectal and anal walls, holding one finger in the 
rectum to guide the knife. It will look like a very long wound, and 
yet it has the excellence of favoring recovery and of preventing a 
fistula. However, under the most favorable circumstances, it may 
require several months to heal (Lejars). 

PERI-ANAL ABSCESS 

These are much less serious than those of the ischio-rectal region, 
both with regard to prognosis and treatment. However, if neg- 
lected, they are likely to result in fistula; even if not properly in- 
cised they may so result. The peri-anal abscess is in the glands 
surrounding the anal margin and lies under the integument or 
mucous membrane. Local anesthesia is all that is necessary except 
for those who are timid, and with them general anesthesia is 
indispensable. 

Puncture the tumor at its apex. The pus is foul smelling. Irri- 
gate; explore the cavity methodically with a grooved director. 
There is nearly always an ascending diverticulum on the anal side 
which communicates with the rectum. Having located the apex 
of the cavity, push the point of the director through the mucous 
membrane; in other words, make a fistula if one does not already 
exist (Fig. 312). Divide all the tissues over the director, in this 
manner laying open the cavity and anal margin. Carefully wipe 
out the walls of the abscess and pack with iodoform gauze. As 
important as the operation is the after-treatment. This the doctor 



404 ABSCESS 

must attend to himself. The dressing must be made daily, washing 
and packing lightly. After each movement of the bowels, the 
wound must be washed and the packing replaced, if possible. It 
is essential that the cavity granulate from the bottom. Repress 
excessive granulation with tincture iodine. 




Fig. 312. — Incision for peri-anal abscess. {Veau.) 

PROSTATIC ABSCESS 

The prostate gland, about the size and shape of a chestnut, lies 
at the base of the bladder, clasping but not quite encircling the first 
portion of the urethra. The upper surface of the urethra is covered 
by fibrous tissues which connect the upper surface of the two lateral 
halves of the prostate, so that the urethra apparently makes a 
tunnel through the prostate. The ejaculatory ducts empty into 
this portion of the urethra. 

The prostate is in contact with the second portion of the rectum 
1% to 2 inches from the anal orifice. The apex rests against 
the triangular ligament, which separates it from the bulb of the 
urethra. 

Suppurative inflammation in the prostate originates from infec- 
tion caught up by the lymphatics of the prostatic and membranous 
portions of the urethra. These infective agents are the gonococci, 
staphylococci, streptococci, bacilli coli communis. 

As might be expected, gonorrhea is the most frequent cause, both 
directly and indirectly. The passage of sounds, perineal bruises, 



PROSTATIC ABSCESS 405 

sexual excesses, and high living in one way or another favor the 
development of an inflammatory process which may result in 
abscess-formation. 

The abscess may be limited to the gland substance or may develop 
in the connective tissue surrounding the gland. In this case it 
may be called a pelvic abscess. It may become an ischio-rectal 
abscess. 

Chronic prostatic abscess may be overlooked and unrecognized 
as the direct cause of many conditions: chronic urethral discharge; 
vesical and rectal irritation; rectal fistula; chronic inflammation of 
the prostatic adnexa (the ejaculatory ducts and seminal vesicles); 
suppurating epididymitis and orchitis; nocturnal emissions. 

Any abscess of the prostate may open into the rectum, bladder, 
urethra, perineum, or suprapubic region. Finally there is, in the 
case of actue abscess, the imminent danger of the general involve- 
ment of the pelvic fascia, ending in septicemia. It is manifest that 
a prostatic abscess is a constant menace. Its evacuation must 
not be delayed. It cannot be denied that oftentimes spontaneous 
evacuation is followed by a complete cure, but the outlook is many 
times more favorable with immediate operation. Sometimes the 
only cure is in complete removal of the gland. 

Diagnosis. — There is usually a history of gonorrhea, recent or re- 
mote. Fever and a few chills; violent perineal pain, radiating to the 
rectum and thighs; painful and difficult urination and defecation 
point to probable suppuration in the prostatic region. A little 
later perhaps the perineum is reddened, swollen, and infiltrated. 
Complete the diagnosis by introducing a well-oiled finger into the 
rectum, which will excite much pain. On the anterior wall of the 
rectum will be found a large unsymmetrical swelling, more or less 
clearly fluctuating, and which loses itself in a doughy tumor extend- 
ing toward the sides of the rectum and the anus. Now must one 
operate even though there be some pus discharging through the 
urethra, having begun spontaneously or following the passage of a 
catheter. Such drainage is quite insufficient. 

There are two methods of operation: (a) the rectal route when 
the abscess is about to burst into the rectum; (b) the perineal route, 
under all other conditions. In either condition general anesthesia is 



406 



ABSCESS 



indispensable. The perineum and its vicinity are carefully sterilized 
and the patient placed in the lithotomy position for the perineal 
incision. 

Rectal route: Place the patient on the right side, flex the left thigh 
on the abdomen and let the assistant hold up the left buttock. 
Dilate the anus and give the rectal mucosa a thorough lavage, wash- 
ing with soap and water and gauze, followed by an alkaline antiseptic 
solution. 

Retract the posterior wall of the rectum with a Sims' speculum. 
The anterior wall will thus be exposed to inspection. Locate by 




Fig. 313. — Prostatic abscess; patient in lithotomy position; incision between bulb 
and anus extending laterally to the ischial tuberosities. (Veau after Pierre Duval.) 



touch the thinnest part of the abscess wall, for the tumor will not be 
so conspicuous to sight as it is to the touch. Without hesitation 
push the point of the knife % inch into the tumor. This is 
to be done by sight and not by touch. When the pus flows, enlarge 
the opening, cutting toward the anus. Make the opening at least 
an inch in length. Favor the flow by slight pressure, and finally 
irrigate. You may be satisfied with that, leaving no drainage, but 
repeating the rectal flushing several times daily at first. If the 
cavity is deep and if there is considerable oozing, it is better to 



PROSTATIC ABSCESS 



407 



pack very lightly with aseptic gauze, which will be expelled with the 
first movement of the bowels. 

Perineal route: An incision 1 inch in front of the anus, transverse, 
slightly curved with convexity forward (Fig. 313). This incision 
divides the skin and superficial fascia — edematous, it may be. 
Separate the edges of the wound and identify, if possible, the muscu- 
lar layers composed of the transversus perinei, the sphincter ani and 
accelerator urinae, which, coming from the cardinal points, meet at 
the " central tendinous point of the perineum," which is to be next 




Fig. 314- — Prostatic abscess. Showing relation of structures concerned in operation; 
in front the bulb of the urethra, on either side of the erectors of the penis, transversely the 
transversus perinei which is divided parallel with its fibers. (Vean after Pierre Duval.) 



incised. If these structures are not recognizable, the bulb of the 
urethra covered by the accelerator urinae can at least be found. It 
is a prominence which the finger if not the eye will readily detect. 
Incise transversely through the middle of the transverse perinei 
(Fig. 314), or at least just behind the bulb. The transversus perinei 
artery will be divided. Now draw the bulb forward out of the way 
with a retractor and pull the posterior lip backward with an artery 
force}).-. 

Make the third transverse incision through the layer now well ex- 



408 



ABSCESS 



posed, viz.: the superficial layer of the triangular ligament, a dense, 
fibrous membrane. The abscess is now covered only by the deep 
layer of the triangular ligament, and this is best opened up with the 
grooved director, working forward in order to avoid the rectum, 
which lies immediately behind (Fig. 315). 

As soon as the cavity is located, enlarge the opening with the 
forceps, irrigate gently, place a drainage-tube and use an absorbent 
dressing, which is to be removed each morning and evening and after 
stool. 







Fig. 315. — Prostatic abscess; showing relation to bladder and rectum and the muscular and 

fibrous layers to be divided. (Veau.) 



Irrigation and Drainage of the Seminal Duct and Vesicle. — -Purulent 
accumulations in the seminal vesicles demand relief on account of 
the frequent urination and other symptoms which sometimes may 
be attributed to the prostate itself. 

Belfield, of Rush Medical College, accomplishes the relief of these 
conditions by drainage through the vas deferens. 

The vas deferens is caught between the fingers at the base of the 
scrotum and brought up against the skin and held by a half -curved 
needle passed through the skin under the vas. A half-inch incision 
under local anesthesia is then made over the vas; it is exposed and 



VULVAR ABSCESS 409 

opened by a longitudinal or transverse incision. The blunted needle 
of a hypodermic syringe is then passed into the canal and the solution 
injected. The liquid traverses the vas and the ampulla, and distends 
the seminal vesicles. 

If necessary the vas may be stitched to the skin by a fine silk- 
worm-gut suture, and a fistula thus established, through which 
daily injections may be made. By this means, too, the vas is made 
to serve as a drainage-tube for the ampulla. 

A fine silkworm-gut may be passed into the canal and left until the 
next injection. Belfield recommends the procedure for chronic 
gonorrheal infections of the seminal canal; chronic pus infections 
in the elderly (often mistaken for enlarged prostate) ; for acute gon- 
orrheal spermato -cystitis; and for the abortion of threatened 
epididymitis. 

VULVAR ABSCESS 

The labia majoria are composed of areolar and fatty tissues, 
bounded on one side by skin and on the other by mucous membrane. 
These integuments have many sebaceous follicles and are exposed 
to various forms of infection and traumatism. Along these sebaceous 
follicles and the lymphatics, agents of suppuration may travel to 
reach the areolar tissues, which are so prone to yield to the 
attack. 

The traumatisms of accident and brutality and excessive coitus 
then are the predisposing causes; the streptococci and gonoccoci, 
the specific agents of inflammation of the vulva, which may end in 
abscess. The suppuration takes on the diffuse rather than the 
circumscribed form. The labium majus of the affected side is 
swollen, doughy, reddened, dry, and there are the other local and 
constitutional signs of suppuration. The skin, apparently more than 
the mucous membrane, is involved and the lesser labium, scarcely 
at all. In order to avoid general infection, or an ugly slough from 
spontaneous evacuation, the abscess must be incised immediately. 
The presence of pus can nearly always be determined by fluctuation. 
After careful antiseptic preparation, a vertical incision in the site 
of the greatest swelling, usually in the integument, will be sufficient. 
There are no vessels to fear. Ordinarily, a strip of iodoform gauze 



4io 



ABSCESS 



will furnish sufficient drainage. An absorbent dressing and rest 
will soon bring about a cure. 



VULVO-VAGINAL ABSCESS. (ABSCESS OF BARTHOLIN'S 

GLAND) 

Beneath the vaginal mucous membrane, near the junction of the 
lateral and posterior walls, between the lesser labium in front and 
the triangular ligament behind, is Bartholin's gland, one on each 

side. The gland is normally 
about the size of a small almond, 
and is about i or i^ inches from 
the vulvar orifice. Its duct opens 
into the vulvar canal just exter- 
nal to the hymen or its remains, 
the carunculae myrtiformes. Its 
lymphatics empty into the super- 
ficial glands. 

Its relation of greatest surgical 
importance is with the venous 
plexus (the bulb of the vagina), 
which covers its upper half and 
which may be wounded by too 
free incision. As in the case of 
vulvar abscess, the cause of sup- 
puration is an infective agent, 
most frequently the gonococcus, 
which reaches the gland by way 
of the excretory duct. Excessive 
coitus is a predisposing cause. 
The symptoms at first are those 
of acute inflammation of the vulva or vagina; finally the symptoms 
become localized. 

On examination the vaginal orifice is found to be almost closed 
on account of the swelling, and the mucous membranes hot and dry. 
The examining finger detects on the affected side a well-defined 
body varying in size, perhaps no larger than a chestnut, perhaps 




Fig. 316. — Vulvo-vaginal abscess. 
Direction of incision. 



> as 



PELVIC ABSCESS 411 

large as a hen's egg. It is clearly circumscribed. The labium 
majus is only slightly edematous ordinarily, the lower part more so. 
The abscess must be incised as soon as fluctuation is present in the 
slightest degree. Several serious consequences may attend delay. 
The inflammation may follow the vaginal areolar tissues into the 
pelvis; there may develop a phlebitis, or sloughing of the veins, or 
lymphangitis, or, what is more common, there may result a recto- 
vaginal fistula. 

Operation. — 'Cleanse the parts carefully under local or general 
anesthesia, incise the tumor in the direction of the long axis of the 
vagina from within outward (Fig. 316). Incise thoroughly, as this 
is the means of securing the drainage that will prevent a fistula. The 
incision must not be deep near the vaginal orifice for fear of wound- 
ing the bulb of the vestibule. A strip of gauze will favor healing 
from the bottom of the abscess. The region should be frequently 
douched. 

PELVIC ABSCESS 

Separating the pelvic peritoneum from the organs of this region 
are loose areolar tissues which are prone to suppurate when attacked 
by infective agents, 

Pelvic cellulitis usually begins as a lymphangitis, following the 
absorption of bacteria from some pelvic focus, usually the Fallopian 
tubes. A salpingitis is the most frequent cause of pelvic abscess. 
The arrangement of the fascia and organs is such that the inflam- 
matory exudates gravitate to the cul-de-sac of Douglas. 

Left to its own course, the abscess may open into the vagina, 
rectum, or bladder; less frequently through the abdominal wall, 
saphenous opening, pelvic floor, obturator foramen, sacro-sciatic 
foramen, or into the peritoneal cavity. 

Diagnosis. — The history usually given points to an attack of pelvic 
cellulitis, following an abortion or complicated confinement, or some 
pelvic or abdominal traumatism. The temperature remains about 
ioo° with exacerbations reaching 103 to 104 . There are all the 
symptoms of septic abortion. 

On pelvic examination you are able to define a mass bulging down 
into the recto-uterine pouch. This taken with the fever and pain, 



412 



ABSCESS 



and perhaps some edema of the vulva, points without doubt to the 
nature of the trouble. A colpotomy should be done as soon as 
possible. The instruments needed are a speculum, a vulsellum 
forceps, a long artery forceps or dressing forceps, curved scissors, a 
scalpel, an irrigator, drainage tube, and iodoform gauze. General 
anesthesia is usually necessary, though in the simpler cases local 
anesthesia will suffice. Lithotomy position; the thighs held well 
apart, the shoulders lowered, the pelvis slightly elevated. 




Fig 317. — Incision of the vaginal mucous membrane for abscess in the posterior 

cul-de-sac. (Veau.) 



A careful antisepsis: Shave the vulva and disinfect the inner 
surface of the thighs, and the pubic region as well. Disinfect the 
vagina, rubbing it with soap and water first and being careful to 
reach every part of the mucous membrane, using the finger wrapped 
with sterile gauze. Finally irrigate with 1 to 2000 bichloride or 
other antiseptic solution. Cover the outside parts with sterile towels. 
Now retract the posterior vaginal wall with a Sims' speculum. With 
the vulsellum forceps seize the posterior lip of the cervix and pull the 
cervix forward (Fig. 317). You will now be able to see the site which 






PELVIC ABSCESS 



413 



is to be incised. The tumor may be conspicuous, the edema and 
fluctuation well defined; or nothing but some edema may indicate 
the presence of the deeper seated inflammation. Do not attempt 
a mere puncture, however well defined the pus cavity may be. With 
a curved scissors or scalpel incise the mucous membrane of the vault 
of the vagina 1 inch behind the base of the cervix. Make an in- 
cision from side to side, but do not approach too near the vaginal 
walls else the arteries there may be wounded. Enlarge the wound 
by stripping its edges back a little. The abscess wall is exposed and 
with a little puncture the pus will flow. However, it may be that the 





Fig. 318. — Showing the uterus pulled 
down, preparatory to opening the 
abscess in the posterior cul-de-sac. 
(Vean.) 



Fig 319. — Showing relations of abscess 
in the posterior cul-de-sac. Dotted lines 
represent drainage tube. (Veau.) 



pus is higher up and separated from the mucous membrane by thick 
and edematous areolar tissues, and this must not be taken for the 
abscess. From it will flow a serous fluid which must be accepted as 
a proof of pus higher up. 

With the finger or an artery forceps follow the posterior wall of 
the uterus upward. Do not dissect backward. The rectum is there 
(Fig. 318). Folio w the posterior wall of the uterus to avoid danger. 
There is always some hemorrhage, in nowise dangerous. It may be 
necessary to dissect upward for an inch; it will seem further than it 
really is. 

When once the cavity is opened into, enlarge the orifice and with 
the finger make careful search for a secondary cavity. If you irri- 
gate, do not employ much pressure. Do not pack the cavity with 



414 ABSCESS 

gauze. Introduce a long drainage-tube to the top of the cavity. 
Its lower end must not protrude at the vulva (Fig. 319). Pack the 
vagina lightly, changing the packing every day without disturbing 
the drainage-tube. You may wash out the vagina, but do not use 
much force. Replace the drainage-tube by a smaller one about the 
tenth day if the temperature is normal. It is likely that it will 
be pushed out spontaneously, and if it cannot be reinstated and the 
temperature is normal, it is certain that it is no longer necessary. 

SUBPHRENIC ABSCESS 

A localized peritonitis is possible only in those localities not 
occupied by coils of small intestine. The region immediately below 
the diaphragm is of this character, and it is practically shut off from 
the general peritoneal cavity by the transverse colon and its meso- 
colon. This space is subdivided by the falciform ligament into a 
right, occupied by the liver; and a left occupied by the stomach, 
pancreas, duodenum, and spleen. Guibal describes five sub- 
divisions of the subphrenic space, in any of which pus may collect 
(Revue de Chirurgie, April, 1909). 

One is retro-peritoneal; four are peritoneal. The retro-peritoneal 
space contains the termination of the esophagus, the posterior border 
of the liver, the pancreas, duodenum, colon, and kidneys. 

Of the peritoneal spaces two lie between the liver and diaphragm 
and may be the seat of abscesses following lesions of the liver, gall 
bladder and ducts, pylorus, stomach, and duodenum. The third or 
perisplenic space, may be infected through the greater curvature of 
the stomach, the spleen or splenic flexure of the colon. The fourth 
space, or the posterior gastro-hepatic, may be infected through the 
posterior surface of the stomach, the pancreas, or liver. 

In effect, subphrenic abscess is a localized purulent peritonitis, 
and whatever part the various adjacent organs may play in its pro- 
duction, yet the most frequent cause of subphrenic suppuration is 
appendicitis. The pus forming around the appendix, or behind the 
cecum, follows the ascending and then the transverse colon to reach 
that region. 

Sometimes it is impossible to determine the original focus of in- 



: 



SUBPHRENIC ABSCESS 415 

flammation. Usually, however, if the history of the case is suffi- 
ciently definite, one may arrive at a conclusion. For example, if 
we find a patient with subphrenic abscess and there has been a 
history of gastric discomfort, vomiting of blood, etc., one w r ould 
decide upon perforating gastric or duodenal ulcer. If there has been 
a history of jaundice and symptoms pointing to the right hypochon- 
drium, the liver, or its ducts, should be accused; if there has been 
clear history of previous attacks of appendicitis one need not be in 
doubt as to the starting-point of the condition with which he has to 
deal. 

Diagnosis. — You will have, then, usually, a history of some visceral 
disturbance followed (very quickly in case of perforation of the 
stomach) by a chill, fever, malaise, pain in the upper abdominal 
pole. The symptoms, to be brief, are those of peritonitis anywhere. 
Suspecting from these symptoms an accumulation of pus in the re- 
gion just below the diaphragm, proceed to a methodical examination 
by means of inspection, percussion, and palpation. The quantity 
of pus may be so great, or so near the front, that the bulging of the 
anterior abdominal w r all may settle the matter without further ex- 
amination. In obscurer cases it will be necessary to recall the normal 
limits of dullness, or tympany of the various organs, in order to de- 
termine the nature and degree of their displacement. Remember, 
too, that in all cases following perforation the abscess cavity will 
contain gas which will be another source of confusion. But after 
all, in the typical cases, guided by the history, the symptoms of 
sepsis and the local signs, one can rarely go astray. Aseptic aspiration 
may be resorted to in the doubtful cases, and one need not hesitate 
to aspirate several times. 

But previous to aspiration the patient should be prepared and 
should be operated upon immediately if pus is found. The X-ray 
may be helpful in diagnosis, since it shows an abnormal conformation 
of the diaphragm, and that it is immobile on the affected side. 

The great majority of sufferers from this condition not operated 
upon die from sepsis. A general peritonitis may supervene. Left 
to itself, the pus may open into the alimentary tract, which is to be 
regarded as a complication rather than a cure, for such cases usually 
terminate fatally from slowly increasing sepsis. In rare instances 



416 ABSCESS 






it may open through the abdominal wall. Most often, however, it 
extends toward the thorax, opening through the diaphragm into the 
lung to be coughed up. Oftentimes the imminence of rupture into 
a bronchus may be predicated from increased pain in the shoulder 
of the affected side, increased cough and muco-purulent or sanguineous 
expectoration, and heightened temperature. The pleurisy nearly 
always present may be fibrous, serous or purulent. An empyema, 
so originating, may even mask the primary condition. But whether 
the pus opens into a bronchus, or the digestive tube, or through the 
abdominal wall, the result of nature's drainage is too doubtful. It is 
imperative to operate as soon as a diagnosis is made, for even a latent 
case may fire up suddenly and march to rapid death. The prognosis, 
in fact, does not depend more upon the character and skillfulness of 
the operation than upon its timeliness. 

Operation. — -The method of operation depends upon the location 
of the pus; it may be (A) near the anterior abdominal wall, or (B) 
it may be inaccessible from the front. 

(A) If the epigastric region is bulging, the incision should be over 
its greatest prominence or where the abscess seems to point. Red 
ness and edema of the skin should be taken as an indication that th 
pus is well walled off and that there is no danger of the incision open- 
ing into the general peritoneal cavity, which is an accident always to 
be guarded against. One may cut directly through these tissue 
whether it be in the linea alba or the line of either border of th 
rectus. 

Once the cavity is opened and emptied, it is to be carefully wiped 
out, for there are usually collections in its deeper parts; and before 
drainage is inserted it should be cautiously irrigated with normal 
salt solution. Moynihan recommends the " cigarette drain" 
which may be well saturated with boracic acid. A counter-opening 
in the loin may be required for efficient drainage. The cavity must 
fill in by granulation which may require six or eight weeks. 

(B) i. If the abscess is behind the liver on the right side, an inci- 
sion along the costal margin is perhaps the best. Divide the 
muscles, or even resect the twelfth rib, and then, by blunt dissec- 
tion, follow the under surface of the diaphragm until the abscess 
cavity is reached. If the abscess is retro-peritoneal it may be nee- 



: 

o 



SUBPHRENIC ABSCESS 



417 



essary to expose the upper pole of the kidney and to draw it down- 
ward and forward, exposing the renal fossa on the under surface of 
the liver, and thence work upward between the posterior margin of 
the liver and the diaphragm. Insert drainage-tubes packed about 
with iodoform gauze. 

2. More often it is best to employ the transpleural route (Fig. 
320), which will require resection of a rib or perhaps more than one. 
The incision exposes the eighth or ninth rib — right side; eighth or 
seventh — left side. (For technic of resection of rib, see page 506.) 
The center of the incision lies in the axillary line and about 3^ 
inches of rib are to be removed. 




«t£sc 



Fig. 320. — Subphrenic abscess. Opening in the mid-axillary line. {Bryant.) 



Now determine the condition of the pleura of which the cul-de-sac 
is exposed. In this region the pleura is easily stripped away from 
the chest wall, and so room may be made to open the diaphragm 
without opening the pleural cavity. If this can be done, evacuate 
and drain the abscess as described above. 

Ordinarily it will be necessary to open the pleural cavity, which is 
first to be aspirated if it contains serum; or opened and wiped out 
if it contains pus. If it is not purulent it is likely to become so un- 
less steps are taken to prevent its infection by suturing the diaphragm 
to the upper lip of the opening in the chest wall. 

You are now ready to open the diaphragm and the pus cavity. In 
some cases a perforation will be found in the diaphragm, and this is 
2/ 



418 ABSCESS 

to be merely enlarged; or, if inconvenient for drainage, may be disre- 
garded and the incision made lower down. Drain. 

A single case will exemplify some of the characters and progress 
of the disease. A farmer, thirty years of age, had suffered for several 
years with a severe affection of the stomach, of which no definite 
diagnosis had been made. Though debilitated, he was yet able to 
do his work about the farm. Without warning he was suddenly 
seized with a violent hematemesis. 

The attack continued for some hours without relief and the total 
amount of blood vomited was appalling. But gradually the bleed- 
ing ceased, leaving the patient prostrate. A tardy convalescence 
followed, interrupted by an intermittent fever diagnosed as malaria, 
a month elapsed and he was brought to bed with a fresh access of 
"ague" — chills, fever, and exhausting sweats. At this time a con- 
sultation exposed the real character of the process. There was a 
vast accumulation of pus in the left side involving the abdomen and 
thorax. A constant irritating cough, a bloody sputum, severe pain 
in the left shoulder, and increased fever and dyspnea seemed to 
indicate the nearness of rupture into a bronchus. In fact this occurred 
within a few hours after our examination. A large amount of pus 
was coughed up and with temporary relief. An operation was 
refused. Indeed, it offered but little hope so late in the course of 
the disease. A week later he died. Had the perforation of the 
gastric ulcer been recognized, or even later the character of the sepsi 
been understood, an operation would have saved his life. 

PSOAS ABSCESS 

Psoas abscess is a term sometimes rather loosely applied to puru- 
lent collections in the iliac region. Properly speaking, it is 
tubercular abscess having its origin in caries of the lower cervical 
dorsal, or lumbar vertebrae. 

It is necessary to recall the arrangement of certain muscles an< 
fascias. The psoas muscle, a rounded fleshy mass, lying alongside 
the bodies of the lumbar vertebrae, extends across the pelvic brim, 
and passes in front of the hip-joint to be inserted into the lesser 
trochanter. The iliacus, its companion muscle, occupies the iliac 



PSOAS ABSCESS 419 

fossa and converges below in a tendon which merges with that of 
the psoas. These muscles are covered by the iliac fascia which is so 
attached as to make the iliac fossa practically a closed compartment. 

The fascia is separated from the muscles by a loose areolar tissue 
in which suppuration may originate the which constitutes an iliac 
abscess. This fascia on its other side is separated from the perito- 
neum by another layer of connective tissue — the subperitoneal 
areolar tissue, which is liberally supplied with fatty tissue and con- 
stitutes a site of lowered resistance to germs originating in the pelvic 
viscera, the cecum, the sigmoid, and the appendix. Suppuration 
under this layer usually ends as a pelvic abscess. 

It is evident, therefore, that an iliac abscess beginning as such, 
and abscess in the subperitoneal tissues, are quite distinct from psoas 
abscess, expect that all have common points of possible opening. 
The iliac fascia covers the muscles in the iliac fossa, but it also ex- 
tends upward in such manner as to ensheath the psoas and sepa- 
rate it from the bodies of the vertebrae. 

In the case of caries, the products of decomposition may burst 
through the vertebral ligaments and the sheath, and thereafter follow 
the psoas muscle downward. The muscle itself may be decomposed 
in whole or part, and the accumulating pus may be directed by the 
tubular sheath to its point of termination below Poupart's liga- 
ment to the outer side of the iliac vessels. Or, again, the abscess 
may burst through the sheath higher up and point in the loin 
(lumbar abscess); or may point just above Poupart's ligament in 
the gluteal region, the pelvis, the scrotum, or thigh. 

The diagnosis of psoas abscess rests upon the history of the case, 
which points to spinal trouble, and upon the presence of fluctuating 
swelling in the iliac fossa, or below Poupart's ligament. Usually 
the hip is flexed in some degree, as by that position the tension in 
the psoas is relieved. 

This flexion and some apparent stiffness in the joint might lead 
to a mistaken diagnosis of hip-joint disease. The swelling is to 
be distinguished, also, from a hernial tumor, by the fact that it is 
fluctuating and lies at the outer side of the iliac vessels. 

Treatment. — As in all cases of tubercular abscess, secondary in- 
fection and amyloid degeneration are most to be dreaded. For 



420 ABSCESS 

that reason, spontaneous rupture and treatment by small incision 
and prolonged tubal drainage are equally dangerous. 

As early as possible an aseptic evacuation must be practised. 
This may be accomplished by puncture and the subsequent injec- 
tion of iodoform emulsion; this seems the advisable procedure, if 
the abscess is pointing in the region of Poupart's ligament, and it is 
likely that the destructive process in the vertebra is an abeyance. 
In general, most authorities recommend the operation of Treves, 
by the lumbar route. 

Operation, — Begin by locating the last rib, the crest of the ilium, 
and the outer border of the erector spinae. The incision, 2% inches 
long, with its center half way between these bony landmarks, 
follows the outer border of the erector spinae and exposes at first 
the lumbar fascia. 

Divide the first layer of the lumbar fascia and expose the erector 
spinae. Develop its outer border the whole length of the wound 
and retract the muscle inward, exposing the middle layer of the 
lumbar fascia. Divide this layer which exposes the quadratus 
lumborum. 

Divide the quadratus lumborum along the line of its attachment 
to the tips of the transverse processes, which exposes the deep or 
anterior layer of the lumbar fascia. Divide this layer and finally 
the psoas magnus is exposed. Divide the attachment of the psoas 
magnus sufficiently to introduce the finger, which opens up the 
abscess cavity and determines the condition of the carious vertebra. 

The abscess cavity is to be treated by thorough irrigation with 
an antiseptic solution, wiped vigorously, or even curetted. The 
various layers are sutured without drainage and an antiseptic 
dressing applied. 

Previous to suturing, the cavity may be filled with iodoform emul- 
sion; or, as Walsham suggests, after the cavity is cleansed it may b 
packed with strips of iodoform gauze, which are to be changed on the 
third or fourth day. If at the end of a week no pus has appeared 
and the cavity is lined with healthy granulations, the wound may 
be closed by secondary suture. 



CHAPTER XXI 
PHLEGMON : ACUTE SPREADING INFECTIONS 

The areolar tissues are less resistant than others. The strepto- 
cocci in their mode of development tend to spread out so that, under 
favorable circumstances, the streptococcic infection of the sub- 
cutaneous connective tissues becomes one of the most dangerous 
conditions, demanding immediate and radical surgical intervention. 

The rapid development of toxins makes death from septicemia 
to be feared; or, short of this, there may be great destruction of 
tissue and subsequent loss of function. 

Certain regions, owing to the opportunities for infection and the 
arrangement of the tissues, are more likely to be affected than others; 
but the general symptoms and the principles of treatment are the 
same. 

One peculiarity of this inflammation is that pus is often slow to 
form, so that when the engorged tissues are incised in the earlier 
stages, merely a serum exudes. It is innocent-looking, but it is 
toxic in the extreme. 

The point, then, is this — do not wait for pus formation and 
fluctuation, before evacuating these products. If pus has formed, 
immediately is none too soon to operate. 

In the case of superficial phlegmon of moderate severity, it will 
often be harmless to try to localize the process by the use of hot 
antiseptic poultices or baths, but the safest thing is free incision for 
drainage. 

The incision must reach the deepest layer of the affected tissues, 
as anything less is useless; it may even be harmful by introducing a 
new infection to tissues which were not previously involved. 

Slight injuries, with subsequent localized accumulations of pus, 
are often the source of an infection which attacks the connective 
tissues, reaching them by way of the lymphatics, and then what was 

421 



422 



phlegmon: acute spreading infections 



a mere local and harmless infection at first, becomes a very danger- 
ous diffuse phlegmon. 

These minor conditions, therefore, are emergencies from the point 
of view of prevention. A few examples will serve to emphasize the 
principles governing their treatment. 

PANARIS 

This is an infection involving the tissues about the finger-nail. It 
may be limited to the epidermis, the dermis, the subcutaneous tissues, 
or the periosteum, the last condition being usually called a felon. 




Fig. 321. — Opening a purulent phlyctena or "run a round." (Veau.) 



hat 



Panaris, Subepidermic. — The appearance at first is almost that 
of a blister, and all of the loosened tegument must be removed. No 
analgesia is necessary, as the epidermis is non-sensitive. 

Begin by pricking the phlyctena with the point of the bistoury, and 
then trim around its whole circumference with pointed scissors 
(Fig. 321). 

Carefully observe the denuded surface, and a small opening may 
be found, leading to a deeper cavity (button-hole abscess) which will 
require incision. 

Complete the treatment by a prolonged antiseptic bath and 
antiseptic dressing. 



► t_ 



PHLEGMON OF THE FINGER 



423 



Panaris, Sublingual. — In this form the pus accumulates under the 
nail and loosens it. It will be necessary to remove the part of the 
nail lying over the pus accumulation. A cure can be obtained only 
at that price. 

If it is confined to one side only, the skin is removed as described 
above, the sharp point of the scissors introduced under the nail, 
and enough of it resected to expose the suppurating surface. If both 
sides are involved, remove the nail completely. 

Panaris, Subcutaneous (Felon). — Incise as soon as pus is suspected. 
No harm can be done even if there is no pus, while a day's delay 
after pus has formed may make a great difference. 




Fig. 322. — Illustrating the situation of the pus in a felon; the dotted lines represent the 

limits of the incision. (Veau.) 

Under local anesthesia (Figs. 8, 9), make a longitudinal incision 
in the middle of the palmar surface where the pain is greatest 
(Fig. 322). 

Do not make a mere puncture, as the whole pus cavity must be 
exposed. Incise deliberately and let the first stroke cut long and 
deep enough, after which explore the cavity with a small probe. 

If there is a palmar prolongation, enlarge the opening, and if 
there is a dorsal prolongation, which is quite rare, make a counter- 
incision on the dorsum of the finger. 

Immerse the hand in an antiseptic or normal salt solution for an 
hour. A drainage-tube is unnecessary, if the incision is properly 
made. 

Dress with moist antiseptic gauze and give the hand a hot bath 
with each daily renewal of the dressing. 

After two to eight days, or when suppuration has ceased, employ 
a dry dressing. The dry dressing favors cicatrization, but the 
moist dressing best relieves pain. 



424 



phlegmon: acute spreading infections 



SUPPURATIVE INFLAMMATION OF TENDON SHEATHS 

Every neglected infection of the fingers or palm may become a 
phlegmon of the tendon sheaths. 

The great danger of these phlegmons is destruction or adhesion 
of the tendons, so that the finger remains permanently flexed or 

extended, unsightly, and more or 
less useless. 

A threatened suppuration may 
often be prevented by a prolonged 
immersion in hot antiseptic or 
normal salt solution. This should 
be continued for an hour and used 
twice daily. 

The Bier treatment is excellent 
for this purpose. This treatment 
is to be applied after suppuration 
occurs, but not until the pus is 
evacuated. It shortens the in- 
cision required and the time of 
repair. 

As soon as pus is suspected, in- 
cise freely. Recall the anatomy of 
the parts (Fig. 323). The sheaths 
of the flexor tendons extend into 
the palm, whence the necessity of 
a palmar incision. The tendon 
sheaths of the thumb and of the 
little finger communicate with the 
common tendon sheaths in the 
palm, whence the additional grav- 
ity when they are involved. The 
common sheaths extend from the 
palm under the annular ligament above to the wrist-joint, whence the 
necessity of incision in the forearm. There is in this incision an 
element of danger by reason of the median nerve, which lies on the 
middle of the front of the wrist between the two common sheaths. 




Fig. 323. — Diagram illustrating the 
arrangement of the synovial sheaths in the 
hand. Note that the sheath of the tendon 
of the little finger communicates with the 
sheath common to all the flexors of the 
fingers m the wrist and palm. Note also 
that the sheath of the flexors of the thumb 
extends into the wrist beyond the annular 
ligament. The median nerve passes under 
the annular ligament between these two 
common sheaths. (Veau.) 






PHLEGMON OF TENDON SHEATHS 



425 

The 



The ulnar artery lies on the common sheath on the ulnar side 
incision must pass between the artery and the nerve. 

Phlegmons of the sheaths of the first, second, and third fingers are 
not likely to extend further than the middle of the palm, while, on 
the contrary, phlegmons of the sheaths of the thumb and little finger 
are likely to point above the wrist. 





Fig. 324. — Suppuration of digital syno- 
vial sheath. Incisions. (Veau.) 



Fig. 325. — Opening into the upper part of 
the ulnar synovial sheath. (Veau.) 



Operation for Phlegmon of the Synovial Sheaths of the Flexor Tendons 
in the Fingers. — A general anesthesia is usually necessary, for the 
pain is great. Make an incision about an inch long in the middle of 
the palmar surface over the point of great swelling. Incise to the 
bone to be sure of opening the tendon sheath. The wound must be 
of uniform length in the superficial and deeper tissues (Fig. 324). 
If necessary, make a similar incision over each of the phalanges and 
in thte palm, but avoid opening into the joints. If the sheath is 
distended with pus, a drainage-tube is easily passed through from 
one incision to the other. 



426 



phlegmon: acute spreading infections 



When the pus has been located, immerse the hand in a hot normal 
salt solution for an hour and repeat twice daily. This greatly favors 
the evacuation of pus and subsequent repair. 
Employ moist antiseptic dressings at first. 

Operation for Phlegmon of the Ulnar Synovial Sheath. — 'Continuous 
with the synovial sheath of the flexor tendon of the little finger, the 

ulnar synovial sheath is larger than 
the radial and its suppuration more 
serious. 

These phlegmons are usually con- 
secutive to neglected infections of 
the little finger. 

Complete drainage is indispensa- 
ble. Begin by making an incision 
over the radial border of the mini- 
mal metacarpal (Fig. 325). Avoid 
wounding the palmar arch, which 
might require ligation; but, after all, 
this is not a serious accident and 
permits a freer incision. 

When the pus is reached, enlarge 
the incision so that the tendon may 
be seen the entire length of the wound. 
Superficially and deep, the incision must be of the same length. 

Next introduce a grooved director into this incision and push it 
through the synovial cavity until its point, passing under the 
annular ligament, can be felt beneath the skin of the wrist. Incise 
carefully over this point until it is exposed, keeping to the inside of 
the tendon of the palmaris longus to avoid the median nerve. When 
the point of the grooved director is fully exposed, enlarge the incision 
to an inch and a half. 

No artery of importance will be wounded. Pass a drainage-tube 
through from one incision to the other (Fig. 326). 

Operation for Phlegmon of the Synovial Sheath on the Radial Side. — ■ 
The palmar incision may be made through the muscles of the thumb 
along the line of the metacarpal, but it is preferable to make it in 
the commissure between the thumb and index finger. 




Fig. 326. — Drainage of phlegmon of 
the ulnar synovial sheath. (Veau.) 



PHLEGMON OF FOREARM 



427 



Make an incision two fingers' breadth in length. At the depth 
of 1 or 2 inches you will find the pus. Pass a grooved director 
along the sheath as in the preceding case. It emerges beneath the 
skin above the annular ligament. Locate and expose the point of 
the director; in incising keep to the outside to avoid the median 
nerve. The radial artery is in no danger, as it is too far to the 
outside (Fig. 327). 




Fig. 327. — Drainage of the radial synovial 
sheath. (Veau.) 



Fig. 328. — Drainage completed. 



In the same manner as before, pass a drainage-tube. Immerse 
the hand twice daily for an hour in hot normal salt solution, and 
employ a moist antiseptic dressing. The drainage-tube will probably 
be unnecessary after the eighth or tenth day (Fig. 328). 

SUBAPONEUROTIC PHLEGMON OF THE FOREARM 



By direct infection, or by extension of infection from the hand, 
1 the areolar tissues beneath the fascia of the forearm may become 
the site of a diffuse suppurative inflammation. 



428 



phlegmon: acute spreading infections 



If neglected, it follows the connective tissues into the intermuscular 
spaces and finally all the soft parts are more or less involved. Free 
incision must be resorted to without delay. In the earlier stages no 
pus will be present, but a straw-colored serum pours out along the 
line of incision. 

Operation. — General Anesthesia. Over the site of the greatest 
swelling, make a free incision in the long axis of the member. This 





Fig. 329. — Incising the forearm for deep 
phlegmon. The grooved director search- 
ing for posterior prolongations of the pus 
formation. (Veau.) 



Fig. 330. — Note manner of fixing tubes 
in drainage for phlegmon of the forearm. 
(Veau.) 



incision will traverse a thick, infiltrated layer to reach the aponeurosis, 
which incise carefully, when, in most cases, the pus will pour out. 
Enlarge the opening sufficiently on the grooved director. 

Irrigate thoroughly with hot normal salt solution and mop out with 
sterile gauze. With a grooved director explore all the parts of the 
cavity for a diverticulum (Fig. 329). 



PHLEGMON OF THE NECK 429 

If necessary make a counter-opening. Tie such of the larger 
vessels as are divided and place several large drains (Fig. 330). 
Change the dressing twice daily, irrigating each time with hot normal 
salt solution. 

About the eighth day, smaller drains may replace those first em- 
ployed and these are usually unnecessary after tw T o weeks. Watch 
; the temperature closely. It is rises, there is a retention of pus, the 
site is not sufficiently drained, or there is a new infection. 

DIFFUSE PHLEGMON OF THE ARM 

All the soft parts are involved and -infiltrated with serum. The 
arm is greatly swollen, edematous, and there are marked symptoms 
of septicemia. 

General anesthesia is indispensable. The freest kind of incision, 
even down to the bone from above downward, is essential. Three or 
four such openings are not too many. 

Irrigate freely with hot normal salt or bichloride solution. Moist 
antiseptic dressings should be used and at first should be changed 
several times daily. 

Incision with the Thermo-cautery, Lejars. — -With the thermo-cautery 
make several large incisions in the axis of the member, each at least 
four fingers' breadth in length and about two fingers' breadth apart 
(Fig. 331). Under the skin will be found a thick layer, infiltrated 
with bloody serum. Cutting through this, the aponeurosis appears, 

L which incise and thus expose the muscles. 
On the inner side avoid the vessels. If some of the large sub- 
cutaneous vessels are opened and bleed too freely, tie them. Irrigate 
J and dress with sterile gauze saturated with peroxide of half strength 
Change the dressing and irrigate two or three times daily. 
i Change to dry dressings when granulation is well under way. Later, 
\ skin grafting may be necessary. In the long time necessary for 
I repair, massage and passive motion must be given the muscles. 

PHLEGMON OF THE NECK 

An infection in the floor of the mouth may become diffuse and 
spread rapidly down the neck. The symptoms of sepsis will be 



43° 



phlegmon: acute spreading infections 



aggravated in the extreme and death may rapidly supervene, either 
from sepsis or asphyxia. The whole neck may be brawny and 
edematous, and the patient's condition is pitiable indeed. 

Lejars recommends the thermo-cautery as offering the best hope 
of a cure, though seemingly brutal. 




Pig. 331. — Incising a phlegmon of the arm with the cautery. (Veau.) 

Under general anesthesia several deep vertical incisions are made 
with the thermo-cautery with numerous punctures between (Fig. 
332). Do not go too deep over the anterior border of the sterno- 
mastoid, for the great vessels are there. 

Pack each incision and puncture with gauze saturated with 
peroxide of hydrogen, and cover the whole with a similar dressing 



PHLEGMON OF THE NECK 



431 



and absorbent cotton. The dressing must be kept saturated with 
the peroxide. In the meantime use the antistreptococcic serum. 

Watson Cheyne also urges the use of the serum, but does not use 
the thermo-cautery. His plan is to incise through the deep fascia 




Fig. 332. — Manner of incising phlegmon of neck with the cautery. (Veau.) 



in several places, enlarging the openings by blunt dissection. The 
wounds are to be freely sponged w T ith undiluted carbolic acid, 
powdered with iodoform, and packed with strips of iodoform gauze. 



CHAPTER XIX 
ACUTE OSTEOMYELITIS 

This is an acute infection of great gravity, more often due to the 
staphylococcus or the streptococcus; but, in rare instances, the pneu- 
mococcus, bacillus coli communis, or tubercle bacillus may be the ex- 
citing cause. 

Usually the germ reaches the affected site by way of the blood 
current, originating in a focus quite unsuspected. In every case of 
bone infection especially where first one bone and then another 
is involved, the middle ear conditions must be investigated. 

In many of these cases a quiescent mastoid abscess is the focus con- 
stantly supplying the blood stream with new crops of the infective 
agent. The patient recovers completely only after the mastoid is 
drained. In other cases the germ reaches the affected site by way of 
the lymph channels or by continuity of tissue, the primary focus 
not having revealed itself. But in all cases the predisposing causes 
are found in certain constitutional states and slight traumatisms. 

The diagnosis is not always easy in the beginning, as the constitu- 
tional symptoms may be marked before the local signs are quite 
definite. 

Acute infectious arthritis, the so-called inflammatory " rheuma- 
tism,'' is the wrong diagnosis most often made but this affection 
does not have the symptoms of sepsis, though, indeed, the fever 
may be high. The pain is usually in the joint and usually in more 
than one joint. 

Subacute arthritis likewise involves the joint, although it is to be 
remembered that an arthritis may be secondary to osteomyelitis 
and overshadow it clinically, but the history of the case will usually 
decide between arthritis and osteomyelitis. 

Erysipelas may be thought of when, after a little while, the skin 
becomes brawny and edematous, but in erysipelas the skin is so in- 
volved from the first. 

432 



ACUTE OSTEOMYELITIS 433 

The symptoms may seem to suggest typhoid fever or other infec- 
tious fevers, but these may usually be ruled out by the absence of 
characteristic features. 

The symptoms of meningitis are often present, but by the time they 
arise, the local conditions point to the nature of the trouble. 

The general symptoms are those of sepsis; high fever beginning 
with a chill, rapid pulse, foul tongue, and in the severe cases, pro- 
found prostration, and finally delirium. 

Locally the pain over the affected area is often extreme, and the 
least pressure tends to aggravate it. Gradually, as the inflamma- 
tion spreads from the marrow through the bone to the periosteum, 
the skin begins to swell, redden, become edematous, and finally 
shows fluctuation. 

In the virulent cases not operated upon, the patient dies within 
the first few days from septic infection. In the milder cases, even, 
large areas of the bone necrose. 

The treatment, then, must be prompt. It is an emergency. 
There is only one thing of any use to be done. The suppurating 
marrow must be evacuated and the medullary canal freely opened 
and cleaned out. Local applications, poultices, or even incisions 
through the periosteum are illusory. The bone must be trephined, 
its cavity opened up at its most accessible part, and all the inflamed 
tissue scraped away. The whole extent of the canal may need to be 
opened, irrigated, drained, and treated with vigorous antisepsis. 
Free incision over the affected area, choosing the easiest and least 
dangerous approach, if possible reaching the bone through inter- 
muscular septa; incision and stripping of the periosteum over the 
proposed site of trephining; opening the bone cavity freely, wiping 
out the pus, curetting and chiseling away the necrotic bone, swabbing 
out the cavity with pure carbolic acid followed by alcohol; obliter- 
ating the larger cavities partially with muscle or fat when possible 
and employing tubal drainage — -these are the principles of treatment, 
and aided in this way nature usually effects a cure. 

In the case of long standing where the cavity is surrounded by new 
bone sclerosed and lacking in osteoblasts it may be necessary to use 
an artificial filling. 

28 



434 



ACUTE OSTEOMYELITIS 



Mosetig-Moorhof's 1 iodoform-plombe is applicable to such cases 
as these. It is prepared as follows: 

Equal parts of spermaceti and sesamoil are melted in an evaporat- 
ing dish, then filtered into a Florentine flask and sterilized in a water- 
bath; 40 grams of finely powdered 
iodoform (not crystallized) are put 
into a sterile flask, and 60 grams of 
the hot fat mixture are added, under 
constant agitation. This agitation 
must be continued without interrup- 
tion, until the mass solidifies. The 
flask is closed with a sterile rubber 
stopper. Before using, the plombe 
is to be heated in water-bath to a 
little above 50° C. 

The bone cavity is most carefully 
prepared for the reception of the 
filling. Everything must be re- 
moved down to sound bone. The 
laws of gravity must, of course, be 
observed in filling the cavity. If the 
cavity is large, it is advisable to fill it 
in several steps, letting the plombe 
solidify in one portion, before any is 
poured into another. The cavity 
must be dry before the mixture is 
poured in. This may be accomplished 
by sponging, by the application of 
adrenalin to oozing points, by hot air, 
etc. The course of healing after iodo- 
form filling is aseptic as a rule. Some- 
times the temperature rises within 
the first two or three days — -so-called aseptic fever — which yields 
to a cathartic. The disposition of the sprouting granulations toward 
the solidified plombe varies between complete closure of the wound 
and healing by primary intention, and incomplete closure. In the 

1 Surgery, Gynecology and Obstetrics, Vol. 3, No. 4. 




Fig. 333.— Exposing the tibial crest, 
opening into the subperiosteal abscess. 
(Veau.) 



OSTEOMYELITIS OF THE TIBIA 



435 



first cases, absorption of the plombe is effected through the steadily 
advancing granulations by vital phenomena; in the second, by par- 
tial displacement and expansion. 



OSTEOMYELITIS OF THE UPPER END OF THE TIBIA 

Here the disease occurs more frequently and here, fortunately, is 
most easily operated upon. 

General anesthesia; special isntruments: a mallet, a gouge, a 
periosteal elevator or rugine, and" curette. 





Fig. 334. — Trephining of the tibia: 
making the orifice. kVean.) 



Fig. 335- — Enlarging the orifice and ex- 
posing the medullary canal. KVeau.) 



Begin by elevating the limb to empty the blood vessels. About 
the middle of the thigh apply an Esmarch tube. Do not apply an 
\ Esmarch bandage, beginning at the toe and extending upward, for 
! that only spreads infection. 

On the right side, the incision commences at the level of the tuber- 
' osity and extends to the middle of the leg, following the sharp crest 
of the tibia just to its inner side. However engorged the tissues may 
i be, this first incision reaches to the bone (Fig. 333). 

Often by this first stroke, one opens into a pus cavity. Do not be 



436 



ACUTE OSTEOMYELITIS 



beguiled by this into thinking the operation completed. This collec- 
tion is to be evacuated and drained, of course, but there is another 
one in the central canal. Extend the incision to the limit of the 
loosened periosteum. With the rugine, expose the anterior surface 

of the bone. A fistulous opening 
leading to the medullary canal may 
possibly be found. In any event, 
proceed to trephine. 

At the upper end of the incision 
make an opening with the gouge 
down to the canal. The pus will be 
almost certain to flow, but it is often 
difficult to distinguish from the 
marrow. 

At the lower end of the incision, 
make another opening (Fig. 334). 
If again pus appears, it is certain that 
the lowest limit of the suppuration 
has not been reached and you must 
lengthen the incision. Continue to 
expose the canal until the full extent 
of inflammation has been exposed. 
It may require the removal of the 
whole anterior surface of the tibia, 
but you are engaged in saving life, so 
that bone is a minor consideration. 
Chisel away, then, all the anterior 
wall between the two limits of sup- 
puration (Fig. 335). Curette vigor- 
ously the medullary canal down to firm and uninflamed bone, 
and especially curette the upper part, for there the suppuration is 
greatest. 

In the case of a child, the epiphyseal cartilage is quickly reached, 
and this one should try to avoid, since too free removal will end 
linear growth. 

Mop the cavity with sterile gauze, swab with carbolic acid followed 
by alcohol or Tr. of iodine. If considerable oozing persists it may 




Fig. 336. — Trephining of the tibia com 
pleted. Tubes in place. (Veau.) 






OSTEOMYELITIS OF THE HUMERUS 



437 



be necessary to pack with iodoform on sterile gauze, otherwise simple 
tubal drainage is sufficient. 

The drainage, however, must include the subperiosteal areas as 
well as the medullary canal in the septic cases (Fig. 336). 

If the operation has been delayed, the muscles of the calf may 
be infiltrated with pus and will require drainage as in diffuse phlegmon. 

If there is serous effusion into 
the joint, it will require no 
especial treatment, for it will 
gradually be absorbed as the 
osteomyelitis is cured. 

If the joint is suppurating, it 
is quite different and another 
operation is required (see oper- 
ation for Purulent Arthritis). 

Over the trephined area, ap- 

] ply a moist dressing and change 

daily. As the exudate becomes 

less abundant, change to a dry 

'< dressing and change the pack- 

1 ing in the canal every other 

day. Smaller drains may be 

inserted about the tenth day, and are removed entirely when the 
suppuration shall have ceased. 

As Veau says, this intervention is only the first act of a prolonged 
and tedious process and this the family should understand before- 
hand. After several months, it may be necessary to remove some 
I necrosed bone; and, long after the cure appears complete, the trouble 
may recur. 

OSTEOMYELITIS OF THE UPPER END OF THE 

HUMERUS 

Begin the incision a finger's breadth below the clavicle, following 
: the axis of the humerus. Prolong it downward 5 or 6 inches. 

The incision will traverse the deltoid near its anterior border. Sepa- 
j rating the lips of the wound, divide the periosteum and proceed to 

trephine and drain as in the preceding case (Fig. 337). 




Fig. 337 



-Osteomyelitis of the humerus. 
(Marsee.) 



438 ACUTE OSTEOMYELITIS 

OSTEOMYELITIS OF THE LOWER END OF THE 

HUMERUS 

Make an incision 8 to 15 inches in length in the line of, and 
ending below at, the external condyle. The incision will traverse 
the thick fibers of the triceps. Trephine and drain. If it is neces- 




FiG. 338. — Cross section showing manner of placing drains after trephining the 

femur. (Veau.) 



sary to make an internal counter-opening for a drain, remember 
the situation of the ulnar nerve. If the whole bone is affected, the 
same principles are involved. The prognosis is exceedingly grave. 



OSTEOMYELITIS OF FEMUR 439 

OSTEOMYELITIS OF THE LOWER END OF THE 

FEMUR 

Make the incision along the antero-internal border of the thigh, 
traversing the fleshy vastus internus. 

The femoral vessels are behind this line. The bone is deeply 
placed and the operation difficult, but trephine thoroughly. Drain 
the medullary cavity and the periosteal abscess (Fig. 338). 

OSTEOMYELITIS OF THE UPPER EXTREMITY OF THE 

FEMUR 

Make the incision along the outer surface of the thigh over the 
great trochanter. Divide the aponeurosis of the gluteal muscle, 
trephine, and drain. 



CHAPTER XX 
SEPTIC ARTHRITIS 

Septic arthritis is acute purulent inflammation of the joints, due 
to the presence of an infective agent, more frequently the staphylo- 
coccus or the streptococcus. The infection may reach the joint 
through a wound, by way of the blood vessels or through the lymph 
channels. 

This purulent inflammation, therefore either follows direct injury, 
or is a sequel to various infective diseases, such as typhoid fever, gon- 
orrhea, scarlet fever, or osteomyelitis; but by no means are all the 
joint inflammations following these conditions purulent. 

Purulent inflammations are to be distinguished from non-septic 
inflammation both by the symptoms and the physical signs. The 
symptoms are those belonging to sepsis, for here it exists in a high 
degree. The tongue is brown and the temperature is very high, the 
pulse is weak and rapid, there are the appearances of prostration and 
finally delirium ensues. The pain is extreme and aggravated by the 
least touch. With respect to the physical signs, there is marked 
swelling of the joint and the skin is red and edematous, not only 
over, but above and below the joint, and fluctuation is usually to 
be detected. 

Treatment. — This is an emergency of the first rank. It is an inter- 
vention designed to save the function of the joint; and sometimes 
even life is threatened. 

There is but one indication, once the diagnosis is made, viz. : to 
open the joint by free incision and counter-incision, that every part 
of it may be reached and drained. 

The most careful antisepsis is to be observed. The limb is to be 
as carefully cleansed as if no pus was expected. 

Scrub the skin over the joint (the knee, for example), the upper 
third of the leg, and lower third of the thigh with soap and water and 
with ether and bichloride. Sterilized instruments are to be used; 

440 



ARTHROTOMY OF THE KNEE 



441 



they are simple, a scalpel, a few artery forceps, some rubber drains, 
and an irrigator. The whole aim is to secure ample drainage and 
subsequent antisepsis, and nature will take care of the rest. In cer- 
tain of the joints, however, mere incision may not be sufficient and 
excision must be added. 




Fig. 339 — Septic arthritis. Incisions for drainage of the knee. (Veau.) 

Arthrotomy of the Knee. — Sepsis affecting the knee-joint causes the 
knee to become enlarged, globular in outline, painful, reddened, 
edematous, with constitutional symptoms of sepsis. The operation, 
under general anesthesia, is very simple and without danger. The 
important thing is to open freely. Two incisions are to be made, one 
external and one internal (Fig. 339). 

External Incision. — Locate the lower border of the patella; and, be- 



442 



SEPTIC ARTHRITIS 



ginning a little below this line, make an incision parallel with the 
externa] border of the patella and ending about two fingers' breadth 
above its upper border, which will be near the upper limit of the syno- 
vial sac. This incision traverses the integument and beneath it the 
firm aponeurosis of the vastus externus. As the joint cavity is 
reached, very often the pus spurts out with great force. 




Fig. 340. — Drawing the transverse drain into place. (Veau.) 

Internal Incision. — On the inside, make an incision symmetrical 
with the first, but a little further removed from the internal border of 
the patella. The aponeurosis is here less firm, but the synovial 
cavity is deeper; the swelling is usually greater on the inner side. 
Some of the fleshy fibers of the vastus internus are always divided. 
The cavity is not so easily reached as on the outer side. 

Drainage. — Place a large transverse drain (Fig. 340). But in some 
cases this is not sufficient. The lateral diverticula of the synovial 
sac must be drained separately (Fig. 341). For this two counter- 
openings are required, one on each side. Into one of the incisions 
at its lower part, introduce forceps, and push backward and downward 
through the synovial sac at the level of the interarticular line (Fig. 



ARTHROTQMY OF THE KNEE 



443 




Fig. 341. — Cross section of knee-joint showing that the transverse tube drains the upper 
part; the two lateral tubes the inferior part of the synovial sac. (Veau.) 




Fig. 342. — Manner of making posterior counter- opening for rainage of 

the knee. (Veau.) 



444 



SEPTIC ARTHRITIS 



342). If it is an old arthritis, this is not difficult; but in the case of 
a recent effusion, the ligaments are tense, and the articular surfaces 
are in contact so that the passageway is quite narrow. 

When the forceps, pushed backward in this manner, bulges the 
skin, open the blades, and, between them, make an incision 1 or 
2 inches long. Through this opening in the forceps, draw a drain- 
age-tube into place. ' Repeat the maneuver on the opposite side. 




Fig. 343. — Septic arthritis. 



A# 

Drainage ot the knee complete. (Veau.) 




It is better to make the counter-opening on the external side first, 
as the ligaments there are less tense. The beginner is seldom success- 
ful in making the opening internally. He nearly always pushes the 
forceps backward at too high a level and the point engages in the 
tendon of the adductor magnus. It must be directed downward and 
backward (Fig. 343). When the joint is thus opened, irrigate freely 
with hot saline solution, reaching every recess of the joint and wiping 
with sterile gauze. Aim to clean the whole synovia. If the joint 






PUNCTURE OF THE KNEE 



445 



is putrid, finish the irrigation with peroxide. Do not suture the 
wounds. Employ a moist antiseptic dressing. Immobilize the 
limb on a posterior plaster splint. 

Subsequent Treatment. — Irrigate and dress twice daily for the first 
few days. However, if the temperature falls almost to normal and 
the pain ceases, do not be in a hurry to change the first dressing. 




Fig. 344. — Puncture of the knee. (Lejars.) 
Occasionally it is desirable to empty the knee-joint, as in the case of a voluminous 
hemarthrosis or serous exudation. The same careful asepsis is practised as for arthrot- 
omy. Locate the upper external angle of the patella. A little above and to the out- 
side of this point, plunge the trocar directly into the joint. The structures here are quite 
resistant, but there are no vessels likely to be wounded. As the exudate flows out, gently 
compress the joint to empty it. Withdraw the trocar with a quick movement, apply a 
sterile dressing, and bandage the knee in absorbent cotton. 



If the suppuration diminishes about the end of the first week, put 
in a smaller drain in the same manner as before, and employ dry 
dressings. Watch the temperature. A rise indicates a retention of 
pus and calls for new drainage. Endeavor to avoid permanent 
flexion of the knee, a matter of the greatest difficulty and of the 
greatest importance, for such flexion cannot be corrected. 



446 



SEPTIC ARTHRITIS 



After the second week the lateral drains are removed; and, some 
days later, the transverse drain. After a month, if the inflammation 
is all gone, attempt passive motion; but it is almost a certainty that 
the joint will be stiff; still if it is stiffened in extension, there is no 
occasion for reproach. 




* AM 

Fig. 345 — Arthrotomy of the ankle. Trace of the incisions. (Veau.) 

ARTHROTOMY OF THE ANKLE-JOINT 

This operation is not so frequently required as for the knee. Often 
local anesthesia will suffice. Make the first incision, 2 inches in 
length, over the anterior border of the external malleolus and reach- 
ing a little below its tip (Fig. 345). In the upper part of the incision, 
one may cut freely down to the bone, but in the lower part more care 
must be used. Some small arteries may be divided if one goes too 
deep. 

In the middle of the incision, open the joint, enlarge the orifice, 
and mop out the cavity. 

Introduce an artery forceps and carry it through the joint cavity 
to the opposite side, and over its point make a counter-opening (Fig. 
346). This opening should fall over the tip of the inner malleolus. 



ARTHROTOMY OF THE ELBOW 



447 



As the forceps is withdrawn, it pulls a drainage-tube into place (Fig. 

347)- 

Dressing and subsequent care are the same as in the knee. 

ARTHROTOMY OF THE ELBOW- JOINT 

Make a vertical incision 3 inches in length, with its center over' 
the outer border of the apex of the olecranon, dividing some of the 




Fig. 346. — Septic arthritis. Drainage of ankle-joint. (Veau.) 

fibers of the triceps and anconeus (Fig. 348). Puncture the synovial 
cavity at the middle of the incision and enlarge the opening to corre- 
spond with the incision. Push a forceps transversely through the 
joint at the upper level of the olecranon. Over its point make the 
internal vertical incision. Cut carefully, for the ulnar nerve is here 
in close contact with the posterior surface of the inner condyle. 

Draw a drain into place with the forceps. The dressing and sub- 
sequent care is the same as that described for the knee. 



44 8 



SEPTIC ARTHRITIS 



ARTHROTOMY OF THE WRIST 

Make an external incision between the long extensors of the thumb 
and the extensors of the index-finger, lines which may always be 
determined. Make a second incision on the ulnar side between the 
tendons of flexor and extensor carpi ulnaris. The two incisions may 
be connected by pushing a grooved director through. 




Fig. 347. — Septic arthritis of ankle. Drainage placed. (Veau.) 

ARTHROTOMY OF THE SHOULDER 

This joint may be opened by a vertical incision, beginning at the 
anterior angle of the acromion process and cutting downward in the 
line of the bicipital groove, or the joint may be opened behind along 
the posterior border of the deltoid, splitting the tendons of the in- 
fraspinatus and teres minor. 

ARTHROTOMY OF THE HIP 

The hip-joint, deeply set under a thick muscular mass, may be 
reached either from in front or behind. The aim of any procedure is 



ARTHROTOMY OF THE HIP 



449 



to reach the articulation in such manner as to produce the least de- 
struction possible in these periarticular muscles; and, therefore, one 
must seek the intermuscular spaces, or split the various muscles in 
the direction of their fibers. 

The study of the anatomy of the region demonstrates that several 
pathways to the joint, complying with the above conditions, can be 
found. 

In front, the joint is covered by several muscles whose directions 
correspond to the axis of the thigh — -the pectineus, the iliopsoas, the 




»M* 



Fig. 34 8 « — Septic arthritis of elbow. Incisions for drainage. (Veau.) 



'rectus femoris, in direct contact with the capsule; the sartorius and 
the fascia lata more superficially placed. 

Behind, the joint lies under a group of muscles which are parallel to 
it when flexed at an angle of 45 . These are arranged in two layers; 
in the first, the g. maximus; in the second, the g. medius and the ob- 
turator internus and gemelli; while below and behind is the tendon 
of the obturator externus. 

anterior arthrotomy. — If one wishes to reach the joint from in 
front, he may pass (1) in between the fascia lata and the gluteus 
medius externally and the rectus and sartorius internally. 
29 



45° SEPTIC ARTHRITIS 

(2) Between the rectus and sariorius externally and psoas in- 
ternally. ^ 

(3) ja Through the sheath ofthe'psoas. 

In the first case, the outer end of the neck and the great trochanter 
isVxposed. In the second, the inner end of the neck, and in the third, 
the head of the femur. 

Position. — On the back with legs extended. Operator stands at 
outside with assistant opposite, and second assistant moves the leg 
as directed. 

Incision.— (1) Incision begins above, and finger's breadth inside, of 
ant. sup. spine, and extends downward and inward parallel to the sar- 
torius, for 4 inches. Expose the internal border of sartorius, draw it 
outward. Below it will be exposed the rectus to be drawn outward I 
also. The psoas is exposed and drawn inward to expose the capsule. 

(2) The incision begins directly over the ant. sup. spine, and de- 
scends nearly vertically, bisecting the angle between the sartorius 
and tensor fascia lata. The sartorius and rectus are drawn inward I 
and the capsule exposed. 

(3) Finally, the incision, to follow the outer border of the psoas, 
may begin at the inner third of Poupart's ligament and extend down- 
ward and slightly inward. The psoas is exposed near its inner border 
and opened, avoiding the anterior crural nerve. 

Open the Capsule. — Once the capsule is exposed, whatever the 
route, the muscles are to be relaxed by flexion, abduction, and exter- 
nal rotation which favors their retraction. The capsule thus freely 
exposed is incised to any extent necessary. 

Counter-opening in Capsule. — It may be advisable to make an in- 
ternal incision to secure complete drainage. Make an incision from 
the external border to the pubes downward and outward, exposing 
the space between the pectineus and adductor longus. Avoid the 
obturator nerve. Next introduce a forceps into the opening 
already made in the capsule and let the point emerge at the second 
opening; and, on this point as a guide, the counter-opening is made. 
The forceps is used to draw a large drainage-tube into place. 



CHAPTER XXI 
) FOREIGN BODIES 

THE EYE 

: Foreign bodies lodged on the conjunctiva or cornea are painful, and 
may soon provoke a conjunctivitis, more or less severe. 

The offending particle may be concealed under the lid or be im- 

1 bedded in the cornea. The latter is especially likely to be the case 
with those who have to do with emery wheels. 

The patient's sensation is a very poor guide in locating the object; 

- if it is on the cornea, he is likely to be certain it is under the upper 

[ lid. 

Begin by inspecting the eye under a good light and at various angles. 

* Pull down the lower lid, instructing the patient to look upward. 

v Evert the upper lid. This is done by grasping the eye-lashes be- 

1 tween the thumb and fore-finger and pulling downward, at the same 
time making pressure upon the tarsal cartilage of the lid with a pen- 

; cil, stylet, or the opposite thumb. Instruct the patient to look 

" downward. Combined with this pressure, the eyelashes are now 
pulled upward and in this manner the lid is everted and exposed 
to inspection. The novice does better, perhaps, to stand behind the 

: patient, but the specialist sits in front of the patient and turns the 
lid with one hand. 

If the foreign body is free, it is readily picked up with the point of 
the stylet wrapped with cotton, but if it is imbedded in the cornea, 
considerable curettement may be required to dislodge it. The in- 
strument must be sterile, otherwise corneal ulcer may follow the 

' manipulation. In the case of nervous or sensitive individuals or 
when the conjunctiva is much congested, the manipulation must be 

i preceded by the instillation of a few drops of a 4 per cent, solution of 

1 cocaine, which should be fresh and must be sterile. Everything used 
must be sterile — hands, instruments, cotton, and solutions. 

1 451 



452 FOREIGN BODIES 

Following the extraction, irrigate with normal salt solution and in- 
still two drops of 2 per cent, collargolum solution or 10 to 25 per cent, 
argyrol solution and direct the patient to wash the eye frequently 
with boracic or normal salt solution; if there is much congestion, band- 
age the eye for one or two days. 

If the foreign body has penetrated to the anterior chamber, the iris, 
or the posterior chamber, the immediate treatment must be limited 
to such measure as will prevent infection — -boracic irrigation and 
bandage — until the case can be placed in the hands of a specialist or 
until special text-books can be carefully consulted. 

It may be necessary to employ the X-ray in diagnosis in these 
cases. The extraction may require a delicate operation or the use of 
the electro-magnet, and finally the removal of the globe may be 
necessary. 

Chemical irritants should be removed by free irrigation. For 
lime in the eye, a solution of sugar in vinegar is recommended, the 
sugar forming a soluble compound with the lime. A few drops are 
used, followed by free flushing with water. Afterward atropine, 
gr. 1 to the ounce is imperatve. 

THE EAR 

The foreign bodies most frequently found in the ear are pebbles, 
shoe-buttons, peas, beans, pens, pieces of tooth-pick, pieces of cotton, 
etc., etc. 

Children may place these objects in their ears in play or innocent 
experimentations or adults may meet with the accident, attempting 
to relieve an itching in the auditory canal. A tampon may be left 
in the ear by the doctor. The body usually lodges in the outer part 
of the canal, and only reaches the tympanic membrane after ill- 
advised efforts at extraction. 

The pain and discomfort are usually moderate; and, as a rule, there 
are no very urgent indications for intervention. But if the object 
rests against the drum, the pain is severe and may even produce 
mental disturbance. 

The first thing to do, then, is always to confirm the diagnosis. The 
patient's belief in the matter must, under no circumstances, be ac- 



FOREIGN BODIES IN THE EAR 453 

cepted as final, There is only one way to confirm the diagnosis and 
that is by careful inspection of the whole canal, if the object is not 
seen in the outer portion. 

Draw the external ear upward and backward, and the tragus for- 
ward. Under good illumination and with the aid of a head-mirror 
and otoscope, the drum is readily seen. If no foreign body can be 

; seen, and provided there have been no blind efforts at extraction, it 
may be definitely concluded that the patient is mistaken. 

If, on the other hand, you locate the object, do not hurriedly intro- 
duce a forceps into the ear; unless, indeed, the offending body is of 
such a nature that it may be easily seized, for you will almost always 

; make matters worse, pushing it further into the canal. Remember 




Fig. 349. — Ear forceps. 

that however desirable it may be to empty the ear, there is, as a rule, 
no great urgency in the matter and you have plenty of time to take 
counsel with yourself (Fig. 349). 

In some cases, a small hooked instrument may be cautiously 
pushed past the object and withdrawn, pulling the object out, or a 
small blunt curette may be similarly employed. Usually a large 
syringe is the proper instrument. Throw a stream of warm, sterile 
water into the ear with the purpose of forcing the body out by the 
"vis a iergo" 

To inject the stream properly, lift the pinna upward and backward 
as in inspection, and direct the stream along the posterior superior 



454 FOREIGN BODIES 

wall, using moderate force. Use one syringeful after another, until 
the offending substance is washed away or the patient is tired out. 

If you have failed, instill into the ear a few drops of glycerine or 
warm oil, lightly tampon, and direct the patient to sleep on the 
affected side, returning the next day for another trial. The chances 
are greatly in favor of ultimate success without injury to the ear. 

In the case of a live insect in the ear, fill the ear with oil and sub- 
sequently the " cadaver" may be removed by irrigation. 

If " instrumentation " seems advisable, there must be no blind 
grasping for the object — it must be kept clearly in view. It has 
happened, in violation of this rule, that the middle ear has been in- 
vaded and the ossicles dragged out. Death has occurred from such 
manipulation, though the post-mortem showed that no foreign body 
had ever been present. 

In the case of children, instrumental extraction will, as a rule, re- 
quire an anesthetic. If the ear has become much inflamed or the 
body pushed through the drum, the case is one for the specialist. 

On the whole, the practitioner might adopt the rule, that if left in 
the ear, untouched, the foreign body is less likely to do harm than 
rude and maladroit efforts at removal. 

THE NOSE 

The catalogue of bodies, recorded as lodged in the nose, is long. 
Naturally, children are more frequently the subject of these mishaps 
although lunatics and hysterical women may intentionally plug the 
nose. Occasionally, a foreign body previously swallowed, may be 
coughed up and lodge in the posterior nares. Pledgets of cotton and 
pieces of gauze, which have been used as tampons, may be over- 
looked and act as foreign bodies. 

In the case of the irresponsible, the presence of a foreign body may 
not be suspected, so few are the symptoms, until there develops a 
profuse sero-mucous discharge. There may be frequent attacks of 
sneezing; and, if the body remains long, the mucous membranes be- 
come swollen and perhaps the skin of the affected side also. There 
may be headache or facial neuralgia. These foreign bodies should be 
removed as soon as possible, first having determined their nature, 
size, and situation. 



FOREIGN BODIES IN THE PHARYNX 455 

Begin by a careful examination of the anterior nares; and, if this 
is not sufficiently instructive, examine the posterior nares by hooking 
the finger up behind the soft palate. The examination and removal 
are often facilitated by the use of cocaine, and in the case of children, 
a few whiffs of chloroform may be necessary. 

Chloroform is also the effectual remedy for animate foreign bodies, 
such as insects and maggots. Used for this purpose, it is not inhaled, 
but is shaken up with an equal amount of water and syringed into the 
nose before the two ingredients separate. 




Fig. 3SO. — Angular forceps for foreign body in the nose. 

A body lying in the anterior nares is usually readily removed by a 
mouse-toothed forceps; or a curved probe or small curette may be 
necessary to dislodge it. An angular forceps is sometimes conven- 
ient (Fig. 350). In other cases, the obstruction may be removed 
by drawing a tampon through the nasal cavity from behind, as recom- 
mended by Sajous. 

If the body is lodged in the posterior nares, it is usually pushed 
backward into the pharynx, care being taken that it does not drop 
down into the larynx or esophagus. 

"In the case of infants, a small body may be removed by blowing 
forcibly into the mouth." (John J. Kyle.) 

PHARYNX AND ESOPHAGUS 

Many diverse objects may lodge in these passageways, either 
through ineffectual efforts at swallowing or by inadvertently slipping 



456 FOREIGN BODIES 

from the mouth. False teeth are often loosened and carried into the 
pharynx or esophagus during sleep. 

The point of lodgment, the immediate effect, the dangers, and 
the difficulty of removal, depend upon the size and shape of the 
object. 

The pharyngo-esophageal canal is narrowest behind the larynx, 
opposite the cricoid cartilage and the sixth cervical vertebra; at this 
point a large body is likely to lodge. A second constriction lies 
2% inches further down, behind the left bronchus; and a third 
where the esophagus passes through the diaphragm. Larger 
bodies, then, are liable to lodge opposite the larynx. Sharp 
and pointed objects, such as needles and fishbones, may anchor at 
any point without reference to the caliber of the conduit. 

The immediate effects of the lodgment of a foreign body vary 
from instant asphyxia to merely slight difficulty in swallowing. 
Later there may occur, even in the case of a slight obstruction, the 
dangerous conditions following infection — erosion of the walls, 
perforation of the bronchi or lungs, of the pericardium, the aorta, or 
carotids — one has but to think of the numerous relations of the 
esophagus in the neck and thorax to understand how diverse the 
consequences of such spreading infection might be in various cases 

Very naturally, the deeper down the object lodges, the greate 
the difficulty in locating and reaching it. 

Treatment, — -Asphyxia, due to occlusion of the lower part of the 
pharynx involving the larynx, demands immediate action. The 
patient is livid, gasping, and struggling. Run the finger into the 
throat over the epiglottis, where the body may be felt and hooked 
out. If you fail in this, do not waste time in these cases of extreme 
urgency, trying tentative measures, such as inversion, but do a 
tracheotomy, or laryngotomy in the adult (see page 477). After the 
operation, the foreign body may be expelled spontaneously in the 
efforts of coughing or vomiting. 

In the less urgent cases, the first indication is to confirm the diag- 
nosis and definitely locate the object. The sensation of the patient 
is not sufficient index as to the presence and situation of an obstruc- 
tion in the gullet, for the pain may be due to a wound made by the 
foreign body in passing. 



; 



FOREIGN BODIES IN THE ESOPHAGUS 



457 




Inspect the mouth, the fauces, and the tonsils. Palpate the region 
of the glottis and behind the soft palate. Palpate externally along 
the anterior border of the sternomastoid, pressing deeply to reach the 
esophagus, most superficial on the left side. Even if, as a result of 
this palpation, the foreign body is believed to be located in the neck, 
it is better to make certain by passing an esophageal sound. 

In certain instances, the X-ray will be invalu- 
able, though not always to be relied upon. In 
the hands of the expert, the esophagoscope has 
proved to be useful. In the course of time this 
instrument will probably come to be a part of 
every doctor's "arsenal." It not only makes 
exact diagnosis possible, but enables the foreign 
body to be removed by sight, avoiding thus the 
injuries to the esophagus which blind efforts 
often produce. 

The presence and location of the foreign 
body once established, extraction is indicated. 
Inversion is illusory and emesis dangerous. 

If the body is in the pharynx, it may be seized 
with curved forceps, or dislodged with the finger 
or an improvised hook. To employ the forceps, 
seat yourself before the patient, whose mouth 
is propped wide open. When the object is 
once seized, incline the patient's head forward 
as the forceps is withdrawn. If you lose your 
hold, rapidly withdraw the forceps and remove 
the mouth gag and often the loosened object will be coughed out. 

In the case of an infant, place the patient on its back with the head 
hanging over the edge of the table, thus preventing the body from 
dropping into the larynx. (Have everything ready for tracheotomy.) 

In extracting a body from the esophagus, the greatest caution is 
necessary to prevent laceration. Rough manipulation only aggra- 
vates the muscular spasm, which is always present in some degree, 
and which, more than anything else, prevents the body safely reach- 
ing the stomach; and these esophageal muscles are exceedingly strong. 
The esophageal forceps is used as in the pharynx. 



Fig. 351- 

hair probang. 
and closed. 



Horse- 
Open 



458 



FOREIGN BODIES 



The horse-hair probang (Fig. 351), introduced past the object, 
opened up and then withdrawn, often succeeds in removing an im- 
planted needle or fish bone. 





Fig. 352. — Coin catchers. 



In the case of a coin or similarly shaped object a "coin catcher 
may be employed (Fig. 352). Introduce the left indexfinger as a 
guide and pass the instrument along its posterior wall until the coin 
is felt, when the catcher is passed on beyond it. Now tilt the handle 
forward and slowly withdraw the instrument until assured by the 

sense of touch that the coin is engaged. 
Completely withdraw the instrument 
by steady, continuous, vertical trac- 
tion. When the pharyngeal orifice is 
reached, it is necessary to accelerate 
the movement to achieve the final ex- 
traction (Fig. 353). 

If, in the course of the manipulation, 
the foreign body is dislodged and slips 
on down into the stomach, do not re- 
gard it as a calamity, unless the object 
is very pointed. Indeed, if the object 
is deeply located, is known to be harm- 
less in character, and extraction seems 
impossible, an effort should be made 
from the first to push it on into the 
stomach with the esophageal bougie. 
This should never be done, if the 
character of the substance is unknown. No effort should be pro- 
longed and above all else, no violence, is permissible. Finally, if 
extraction fails and propulsion into the stomach is out of the ques- 
tion, there is only one thing left to be done — an esophagotomy. 




Fig. 353- 

the esophagus 



Extracting a coin from 



(Lejars.) 



FOREIGN BODIES IN THE ESOPHAGUS 459 

In certain cases where the body is firmly implanted, or when it is 
pointed and dangerous to move, resort must be made to the operation 
at once (see page 484). 

LARYNX AND TRACHEA 1 

The air passage is frequently involved, an accident always of con- 
cern, often serious, and sometimes fatal. 

The bodies finding their way into the larynx and trachea are of 
great variety, fluid and solid, animate and inanimate; most often 
aliments perhaps, and after these, the list may be indefinitely ex- 
tended. 

Children are more often sufferers, because of their habit of putting 
objects into their mouths at random. Many times particles of food 
"go the wrong way," the result of the patient's speaking or laughing 
during the act of swallowing: the epiglottis is raised inopportunely, 
and the morsel drops into the larynx. Small bodies are inhaled in 
ordinary breathing. The accident sometimes happens during sleep, 
through the dislodgment of false teeth or something held in the 
mouth; it may follow an attack of vomiting, or it may occur during 
some operation about the mouth; conditions such as anesthesia, 
which diminish the reflex irritability or motility of the larynx, favor 
it. 

The point of lodgment depends chiefly upon the size and shape of 
the object. Pointed objects, such as pins and fishbones, frequently 
stick in the supraglottic portion of the larynx; flat bodies, coins and 
buttons, usually lodge in the ventricles, while small globular, heavy 
bodies descend into the trachea or bronchus, usually the right. 

The symptoms and sequelae, and therefore the dangers, may be 
grouped under two heads, obstructive and inflammatory. 

(a) If the body is large and lodged in the larynx, asphyxia may be 
the immediate result and may be almost immediately fatal. Even 
small bodies may produce fatal asphyxia through reflex spasm of the 
glottis, though usually the reflex spasm subsides. Reflexly, also, 
coughing, sometimes violent, is induced, and this may be the case 
whether the body lies in the larynx, trachea, or bronchus. Some- 

1 Quotations are from Von Bergman. 



460 FOREIGN BODIES 

times the body may lodge between the vocal cords, thus preventing 
their closure and allowing some air to pass so that life may be sus- 
tained for some time. 

If the body is lodged in the ventricles, there may not be so much 
obstruction, but there is hoarseness or aphonia and cough. 

If the body descends into the trachea, there may be no indication 
of obstruction, but there is much reflex irritation, evidenced by pain 
and cough. If the body is light, it may move backward and forward 
in the trachea, following the current of, air. 

If a bronchus is obstructed, a whole or a portion of the lung may 
collapse, evidenced by altered auscultatory sounds. 

(b) The body may become encysted if not removed, or inflamma- 
tion may ensue with the most diverse sequences, depending upon the 
location of the object: edema of the glottis, diphtheritic inflamma- 
tion, abscess of the larynx, phlegmon of the neck, hemorrhage due to 
erosion of the large vessels or even of the heart, tracheitis, bronchitis, 
bronchiectasis, pneumonia, gangrene of the lung, empyema, purulent 
pericarditis, mediastinitis, or phthisis. 

Treatment. — Asphyxia demands immediate action; there is no time 
for examination and inquiry. Make a hurried effort to remove the 
body by passing the finger into the larynx, and if this fails, without 
further delay do a tracheotomy (see page 481). 

In the less urgent cases, one may be more deliberate, endeavoring 
to ascertain the character of the object and to locate the point of 
lodgment. The history of the case, the symptoms and the physical 
signs derived from auscultation, will furnish valuable information. 

Various procedures are recommended. 

" Inversion and violent shaking of the body do not enjoy their 
former popularity. Even the conservative Weist considers manipu- 
lation of this sort dangerous and only justifiable after tracheotomy." 

Still it does not seem likely that it can result in harm if the body 
is known to be small so that it may readily pass between the vocal 
cords. 

"The simplest way is to follow the suggestion of Sanders, and let 
the body hang over the edge of the bed and rest on the hands during 
the attack of coughing.'' "Generally speaking, emetics are unre- 
liable and their use not without danger," 



BRONCHOSCOPY 



461 



If there is time, the laryngoscope may be of great aid in diagnosis 
and extraction, employing cocaine in the adult and chloroform in 
children. ^^^ 



In the hands of the skilled, the broncho- 
scope often furnishes a happy solution to 
the difficulty (Fig. 354). It is to be hoped 
that the technic of bronchoscopy, now 
familiar only to the specialists, will soon 
be popularized with the profession at 
large. In cases less urgent, the X-ray 
may be used to locate the substance. 

But after all, tracheotomy or laryngot- 
omy is the chief reliance of the practitioner 
left to his own resources, and he must be 
prepared for immediate operation while 
other measures are tentatively tried* 
Lejars urges that an attendant be at hand 
ready for instant operation as long as the 
body is known to be free in the bronchus 
or trachea. 

"It makes no difference what one's 
views are regarding tracheotomy in gen- 
eral; the fact remains that no physician 
will deny the necessity of this step when 
the danger of suffocation is great." 

"The author has become convinced that 
the danger of tracheotomy nowadays is 
insignificant compared with that of a 
foreign body in the air passages and does 
not hesitate, even when the body is situ- 
ated in the larynx, to remove the offending 
material through an incision should extrac- 
tion per vias naturalis be impossible." 

"Tracheotomy is positively indicated 
when the foreign body is movable in the 
trachea." 

In any case after the urgent symptoms have subsided, "operative 




LI 



462 - FOREIGN BODIES 

interference is the special form of treatment most rational and the 
form of operation depends upon the situation." "If the extraction 
means laceration, it is justifiable to split the larynx itself or a sub- 
hyoid pharyngotomy may be indicated." 

"The expectant treatment, to which so many patients formerly 
fell victim, is to be condemned. This method is only justifiable in a 
small number of cases, in which the body has fallen far down into the 
bronchus where it cannot be reached. 

"The death rate shown by statistics should not decide the question 
of operation: the clinical picture of the particular case and the unfor- 
tunate cases should guide the surgeon. Those that died after the 
operation did not do so because they were operated upon, but because 
they were operated upon too late. In an individual case the doctor 
can never count upon spontaneous expulsion. Every hour the of- 
fending material remains in situ lessens the chances more and more, 
while operation furnishes conditions most favorable for its removal. 
Opening the air passages, then, is the most rational procedure except 
for the cases in which endolaryngeal methods can be used." 

RECTUM 

The objects which liave been removed from the rectum atone time 
or another, cover a wide range — bottles, pieces of wood, etc., pushed 
in to stop a diarrhea, to satisfy a perverted sexual impulse, or by the 
insane. 

It is scarcely necessary to indicate all the instruments and artifices 
which have been employed in their extraction, but it is helpful, as 
Lejars points out, to formulate certain general rules of procedure. 

The necessity of these formulae cannot be doubted when one con- 
siders the difficulties of extraction, often considerable, and the fre- 
quency with which the rectum is lacerated by misguided effort. 

Often the patient does not admit the nature of his difficulty, con- 
sulting the doctor on some other pretext, such as constipation or 
some rectal trouble quite different from the real condition. In the 
case of obscure trouble in the natural orifices, the doctor should be on 
his guard. If the nature of the complaint is admitted, proceed to a 
methodical examination and endeavor to get your bearings. 



FOREIGN BODIES IN THE RECTUM 463 

Introduce a finger, which has been well oiled, into the rectum. 
Sometimes you will find the object just within the orifice, of such 
size and shape that it can be readily extracted with the finger or with 
a forceps without further trouble, but you cannot count too much on 
that. 

If the examination shows it to be lodged high up in the concavity 
of the sacrum, impacted and perhaps completely filling the rectum, 
make no effort at extraction, but prepare for a formal operation. 




Fig. 355. — Foreign body in the rectum, b. Bottle; c. Coccyx. (Lejars.) 

Under a general anesthetic, put the patient in the lithotomy posi- 
tion'with the thighs well flexed, the hips elevated, and the anal re- 
gionin a good light. Dilate the anus with the fingers as completely 
as possible and then determine the exact "presentation" of the body. 
Introduce a Sims' speculum, passing it, under the guidance of the 
finger, beyond the coccyx, and then retract as widely as possible. 
This is easily done in the young, but may be difficult in the adult. 

When the coccyx is thus sprung back, the body must be seized and 
traction made in the axis of the outlet if the body is long (a bottle for 



464 FOREIGN BODIES 

example) and firmly fixed (Fig. 355). The fingers or forceps may be 
used. If you are dealing with glass, the blades of the forceps must 
be covered with rubber to prevent slipping. If the ends of the for- 
eign body are pointed, and imbedded in the rectal wall so that traction 
is dangerous, great care must be exercised. In some cases morcella- 
tion will be possible. 

If the coccyx cannot be retracted and serves as the direct impedi- 
ment, it will have to be resected. If the body has found its way up 
into the left iliac region into the sigmoid, it may possibly be worked 
down into the rectum by external manipulation. Finally, in such a 
case, laparotomy and opening the bowel may be the only means of 
relief. 

Combs, of Indianapolis, reports a case which illustrates the prin- 
ciples of treatment involved (J. A. M. A., Oct. 23, 1909). 

After a drinking bout and a drunken sleep in the woods, the patient 
awoke with a pain in his rectum and found it impossible to empty his 
bowel. He applied to a physician who discovered a beer glass in the 
rectum, inserted there during the victim's drunken stupor by brutal 
comrades. An attempt was made to remove the glass without pre- 
liminary divulsion of the sphincter. During_ traction with forceps 
the glass was broken and the attempt failed. 

Some hours later he was seen at the hospital by Combs who found 
the small end of the glass resting on the promontory, and the large 
end imbedded in the hollow of the sacrum (Fig. 355), its broken 
edges buried in the soft tissues. By reason of the edema and swelling, 
divulsion was insufficient for removal, and consequently the con- 
tracted muscles were divided in the middle line posteriorly, when the 
glass, which was four inches long and seven inches in circumference 
at its large end, was readily removed. On account of the swelling 
and evident infection, the incision was left to heal by granulation, and 
on discharge from the hospital the patient had a perfect control of 
the sphincter. Combs remarks that the shape, size, and nature of 
the foreign body, the edema and swelling, and the degree of trauma- 
tism will be the guiding indications for the course to pursue. It 
would certainly seem a rare instance in which amputation of the 
coccyx would be required. Adequate division of the muscles poste- 
riorly with quick removal is advised in lieu of prolonged efforts at re- 






FOREIGN BODIES IN THE URETHRA 465 

moval by traction, especially of an object with cutting edges from 
which fatal wounds may result. 

THE URETHRA 

A piece of sound may be broken off in the urethra. Boys or the 
insane may lose various objects in the urethra, slate pencils, pipe 
stems, pieces of watch chain, etc. 

As a rule, the accident is not immediately disastrous, for generally 
the impediment to urination is not complete. The object should 
be removed as soon as possible and with as little irritation to the 
urethra as possible. 




=@4I 




Fig. 356. — Urethral forceps of Collin U), Leroy d'Etiolles (&), and Hunter (c). 

It is necessary merely to enumerate some of the methods employed 

successfully in various cases, and each case must be treated on its 

own merits. Often the body may be easily reached and extracted 

\ with forceps (Fig. 356). In certain instances, it may be gradually 

worked forward by external pressure; or in urination the meatus may 

be pinched up and when the urethra is ballooned out by the pressure 

of the urine, sudden release may result in the body being washed out. 

In case the body is in the deeper part of the urethra, and con- 

, siderable manipulation is necessary, pressure should be applied over 

the urethra on the bladder side of the foreign body, to prevent its 

. being pushed deeper. A piece of hollow sound or catheter may some- 

i times be removed by passing a smaller sound down into its lumen; 

30 



466 



FOREIGN BODIES 



1 



or the urethral speculum or a larger hollow sound may be passed! 
down to, and over the body, which permits its more ready seizure by 
a forceps passed through the speculum. 

Dayat shaped a lead sheet into the form of a hollow sound and, 
passing it beyond the object in the urethra, closed its lower end by 
pressure over the urethra and in removing the lead catheter the 
foreign body came out with it. 




Fig. 357. — Extracting a pin from the 
urethra by "version." Protruding the 
point through the skin. (Bryant.) 



Fig. 358. — Point grasped with forceps. 
Its direction reversed and head brought 
out through the meatus. (Bryant.) 



In another case, a stick forced into the urethra could not be with- 
drawn on account of a hook on its lower end, but after being split into 
many pieces, its extraction was accomplished piecemeal. 

In the case of a pin lost in the urethra head downward, its point 
may be driven through the skin and " version" accomplished and the 
head brought out through the meatus (Figs. 357, 358). 

In other cases it may be necessary to do an external urethrotomy, 
and finally the object may have to be pushed into the bladder and 
removed by suprapubic cystotomy. 



FOREIGN BODIES IN THE BLADDER 467 

Hazzard describes a case in which a hat pin was lodged in the ure- 

j thra, its head too high to manipulate. He bent the penis at a right 

angle to the direction of the pin and thus thrust its point through the 

1, skin, which enabled him to practise version (J. A. M. A., May 29, 

1909). 

Hyde, of Kansas City, reports a shawl pin slipped, head first, down 
the urethra and into the bladder. The point could be felt at the 
penoscrotal angle. An incision was made down to the urethra, the 
point was forced through the urethral wall into the incision, and the 
pin drawn out till the head reached the urethral floor; it was then re- 
versed and delivered through the meatus without opening the urethra. 
The wound was closed by three deeply placed silkworm-gut sutures 
with prompt repair (J. A. M. A., March 13, 1909). 

Charlton of Indianapolis operated on a case at the City Hospital 
in which the patient, a man of fifty had lost the bony portion of a 
dog's penis in his urethra, having inserted it as was his custom to re- 
lieve an itching. Painful micturition was his chief symptom. The 
bone was located in the bladder, a cystotomy performed, the foreign 
body removed, with complete recovery. 



CHAPTER XXII 
BURNS, SCALDS, AND FROSTBITE 

From the point of view of prognosis and treatment, burns are of 
three degrees: 

(i) Transient application of heat, something below the boiling- 
points, produces hyperemia. 

(2) A greater degree of heat or a longer application produces a 
more definite vaso-motor paralysis and there is exudation, particularly 
into the Malpighian layer, and the epidermis is lifted up in the form 
of blisters. 

(3) The albumen of the tissues and fluids is coagulated. This 
necrobiosis may be superficial or it may involve the deep structures 
as well. 

Symptoms. — Even in slight burns, pain is always a prominent 
symptom. In the severer burns, shock is always present in some 
degree, and as the shock disappears, reaction comes on, with rise of 
temperature, and the symptoms resolve themselves into some form 
of internal congestion, or systemic intoxication, characterized by 
hemoglobinuria or albuminuria, vomiting, or bloody diarrhea. After 
a few days the symptoms may be those of septic infection. 

The cause of death from burns falls into four groups: 

(a) Shock. This may be rapidly fatal, sometimes as late as twenty- 
four hours. Death may be due to cardiac paralysis, the result of 
over-heating of the blood. 

(b) Toxemia. The tox-albumens resulting from the chemical 
changes in the tissues find their way into the circulation and over- 
whelm the heart and kidneys, usually within the first two or three 
days. It has been demonstrated that these toxic substances are 
hemolytic and cytotoxic for the parenchyma cells and are eliminated 
from the body by the kidneys and intestinal tract. 

(c) Internal congestion and inflammation } involving the cerebral, 
thoracic, or abdominal structures. 

468 



TREATMENT OF BURNS 469 

(d) Septic infection or its sequelae. This may be fatal after the first 
lew days or only after a prolonged struggle. 
Factors Determining the Prognosis. — (a) Area and depth of burn. 

(b) Age and general condition of patient. 

(c) Region. 

(d) Degree of infection. 

The rules for determining the prognosis can be formulated only in 
a. general way with reference to these various factors, and yet keep- 
ing them in mind, a quite definite forecast may often be made in a 
given case. 

(a) It is the area rather than the depth of the burn which deter- 
mines the danger. An extensive superficial burn is more dangerous 
than a limited but deep one. It appears that under the effect of heat 

"muscular tissue generates a poison much less toxic than that from 
the skin. Mere reddening of two-thirds of the cutaneous surface 
will almost inevitably result in death, while destruction of one-third 
of the skin will probably produce the same result, yet most burns of 
the first and second class commonly met in practice will recover. 

(b) The age and general condition involve the question of the 
j ability to rally from shock and to resist infection. By reason of their 
* lack of resistance to these forces, the young or the aged may succumb 

to even slight burns of the third degree. 

(c) Burns over the head are dangerous for the reason that menin- 
' gitis may develop, and similarly burns of the thorax and abdomen are 

likely to result in lesions of their contained viscera. Burns about the 
face are often accompanied by corresponding injury to the air pas- 
j sages by inhalation of smoke or flames. 

(d) The most important factor, however, in the process of severe 
, burns is infection. Such injuries, in fact, are infected wounds. The 

coagulated albumens of the destroyed tissues are not favorable soil 
for the development of the bacteria, but around the circumference of 
the burn are tissues of lowered vitality which are not only unable to 
resist the encroaching germ, but, more than that, actually nourish it. 

The serous exudates of superficial burns are likewise culture 
media, so that in severe burns as well as in other wounds it may be 
said that the patient's fate lies in the first dressing. 

Treatment. — Slight burns of the first degree require protection, 



470 BURNS, SCALDS, AND FROSTBITE 

which may be furnished by vaseline; by gauze saturated in boracic 
acid solution; by carron oil; by dusting powders of various kinds, 
boracic acid, dermatol, bicarbonate of soda, flour. 

In severe burns the indications are to combat the shock, to relieve 
the pain, and to prevent infection. In the matter of the local treat- 
ment of these conditions, the final word has not yet been spoken. 
The most divergent opinions appear in current literature, and of these 
various lines of treatment perhaps none are wholly bad, certainly 
few are altogether good. 

Begin, then, by combating shock and relieving pain. These two 
conditions are usually relieved at once by frequent but small hypo- 
dermic doses of morphine, supplemented by subcutaneous or venous 
injections of salt solutions. If parts beneath the clothing are in- 
volved, use the greatest care in removing so that the skin will not be 
removed with it. 

To cut the clothing is safer than to attempt to undress the patient. 
Always remember that contact with the clothing may be the chief 
source of infection. 

Now, what will one do to prevent infection? This is the chief 
problem. 

If the burn is of large extent and depth as well and has been in 
contact manifestly with sources of infection, there is but one thing 
to do if the aseptic method is to be employed. Anesthetize the 
patient after the shock has passed and proceed to sterilize the parts. 
Scrub the uninjured skin around the wound with soap and water and 
then alcohol and bichloride. Next proceed to irrigate the burned 
area with normal salt solution, in the meantime carefully rubbing 
with sterile gauze, to the end that every bit of foreign matter may 
be removed. In those parts that are merely blistered, the blebs 
are to be punctured and the serum washed away. It may be advis- 
able, even, for the sake of thorough disinfection, to make no effort 
to spare the cuticle of the blisters in rubbing with the sterile gauze. 

Not hurriedly, but patiently complete this cleansing. It will prob- 
ably require from one-half to three-quarters of an hour, but it is 
time well spent. You have now to deal with an aseptic wound. 

Next cover the area with plain sterilized or borated gauze and 
over this apply absorbent cotton and bandage snugly. 



OINTMENT OF RECLUS 47 1 

If much cuticle has been removed, cover with sterile vaseline 
1 before applying the sterile gauze. 

The aid of a splint may be required to prevent deformity. If 
no fever arises the dressing need not be changed for eight or ten 
f days. 

It may not be practical to institute the thorough disinfection which 

g anesthesia alone permits, but one can at least cleanse the adjacent 

1 area as before described. Prick the blisters and irrigate the burnt 

area with normal salt solution, but in this case sterilization is not so 

much a certainty. 

Therefore, you must employ an antiseptic dressing. Whatever 

i dressing you select should have these properties at least; it should be 

^ antiseptic, analgesic, and teratogenic. A number of substances 

j possess these properties in various degrees and are otherwise more 

or less unobjectionable. 

Picric Acid. — This is employed in solutions of i or 2 per cent. A 
good solution is made by dissolving ij^ drams in 3 ounces of 
alcohol and adding some of this solution to two parts of water. 
After cleansing the surface apply strips of sterile gauze, soaked in 
the solution, cover with absorbent cotton and bandage. Change 
the dressing in three to four days, soaking it loose with the same 
solution. Picric acid stains are removed by an alkaline sulphide 
followed by washing with soap and water or by a paste of manga- 
nese carbonate and water. 

Turpentine. — -This is an excellent domestic remedy, antiseptic and 
analgesic, but only to be employed in slight burns of the first degree. 
Cover the area with absorbent cotton and saturate with the turpen- 
tine, and bandage. 

Aristol. — This, too, renders excellent service. Use as an ointment 
mixed with sterile vaseline or zinc ointment in the proportion of 8 to 
10 grains to the ounce and apply spread on sterile gauze. 

The Ointment of Rectus. — This, perhaps better than any other 
ointment, meets all the indications. It is applied in a thin layer 
directly to the surface or spread on sterile gauze and the dressing 
completed with cotton and bandage. Here is the formula of the 
ointment as modified by the author and prepared by the Pitman, 
Myers Co.^ and which should be ready for instant use: 



472 BURNS, SCALDS, AND FROSTBITE 

1$ — Hydrarg. Chlor. Corros., i part. 

Acid Carbol., 30 parts. 

Aristol, 30 " 

Acid Boric, 90 " 

Salol, 90 " 

Antipyrine, 150 " 

Petrolatum, 576 " 

Carron Oil. — This is an old and useful remedy, but, as ordinarily 
used, unqualifiedly to be condemned. It favors suppuration because 
it is in nowise antiseptic and perhaps may — indeed often does — carry 
infection. If the oil is sterilized and then applied to the surface 
which has been made as clean as possible, it is an efficient 
dressing. 

Granger, of Rochester, Minn., uses equal parts of lanolin and zinc 
ointment spread thickly on gauze, covering the ointment with the 
waxed paper sold by instrument dealers, and applying the dressing 
with the paper next to the burned surface. The dressing is next 
covered with a thin layer of cotton. He claims that it is soothing 
and easily removed. 

The frequency with which any dressing must be changed will 
depend on the pain or infection. If the secretions are excessive and, 
by drying and stiffening the dressing, aggravate the pain, the dress- 
ings must be frequently changed. 

If there is infection, the rise of temperature will be the index. The 
same care must be exercised in changing the dressings as in treating 
any other wound. 

BURNS OF THE MOUTH 

Burns of the mouth and air passages are not infrequent. These 
may be the result of taking hot substances into the mouth or the 
inhalation of hot gases in explosions. Pain and difficulty in swallow- 
ing are the most frequent symptoms. In addition there may be 
edema of the glottis or finally acute bronchitis may develop. Cold 
water and bits of ice give the most relief. The edema of the glottis 
may require tracheotomy. The various forms of inflammation, such 
as bronchitis or pneumonia, must be treated on general principles. 



SYMPTOMS OF ELECTRICAL SHOCKS 473 

ELECTRICAL BURNS AND SHOCKS 

Electrical burns are painful out of all proportion to the size of the 
lesion and require two or three times as long as the ordinary burn for 
repair. 

Begin the treatment with hypodermics of morphia and strychnia 
(1/30). Cleanse the wound by the ordinary surgical methods and 
dress with sterile gauze, cotton, and bandage. 

The resuscitation -of persons shocked by electricity is necessitated 
much more often than formerly by reason of the widespread use of 
the electric current. Spitzka has lately outlined the course to pursue 
in the treatment of such cases. He remarks, in the first place, that 
one cannot safely predict exactly what will happen in any case of 
shock by electricity, for many factors modify the action of the cur- 
rent: its nature, tension, intensity; the resistance and susceptibility 
of the individual; the duration, location, and area of contact. 
Broadly stated, the effect is the more severe, the greater the voltage, 
the greater the amperage, the longer the period of contact, the greater 
the area of contact, and the longer the path of the current through 
the body. 

Death by electrical contact would appear to be due to heart paraly- 
sis or to asphyxia, or a combination of both. In certain cases there 
is no paralysis of the heart, but only respiratory failure. 

The symptoms of electrical shock in cases which are not immedi- 
ately fatal, vary greatly in form and degree. 

I. Local signs: 

(a) Burns and superficial necroses. 

(b) Puncture and rupture of tissues. 

(c) Hemorrhages. 

(d) Edema and erythemas. 

II. General effects: 

(a) Loss of consciousness. 

(b) Paralysis and spasms of muscles. 

(c) Disturbances of respiration and circulation. 
(d)_High temperature. 



474 BURNS, SCALDS, AND FROSTBITE 

Later there may develop disturbances of the bowels, kidneys, 
special sense organs, the central and peripheral nervous system. 

The prognosis is good only in cases where there is some heart 
action and respiration and where treatment can be promptly applied. 

Treatment, — -If the stricken man is not out of the circuit, some cau- 
tion must be exercised in accomplishing his relief. The rescuer 
should have on rubber gloves or have his hands wrapped in thick 
dry, woolen material, to avoid shock from handling the victim. He 
may be freed by pulling at his clothing or using sticks of wood. If 
it is necessary to cut a wire, the nippers must have insulated handles 
and the eyes should be protected from the blinding flash. 

Once freed, the patient should be laid with head elevated and arti- 
ficial respiration at once begun. This is more effectively done by 
compressing the chest with the hands applied flat against the sides 
of the lower part of the thorax. The tongue must be drawn forward 
so as not to obstruct the larynx. Massage over the heart and 
faradism help to stimulate its action. Arterial infusion of adrenalin 
has been proven by Crile and Dolly to have a direct effect. 

Other methods which have been suggested are lumbar puncture, 
venesection, and the high-tension shock of short duration (Jour. 
Med. Soc. New Jersey, Jan., 1909). 

FREEZING 

The effects of very low temperature on the tissues are practically 
the same as those of heat. The ultimate effect is death of the tissues 
or gangrene. 

The treatment of patients overcome by cold must be circumspect. 
The main point is to go slow in warming the parts. The patient 
should never be brought directly from outdoors into a warm room. 
Sonnenburg advises that a cold bath, the temperature of the cold 
room, be used, and the temperature gradually raised until in two 
or three hours it reaches 8o° F. Where life seems extinct, artificial 
respiration should be practised, and sometimes the circulation may 
thus be re-established. Subsequently hot rectal enemata of whiskey 
or coffee may be employed. The limbs and other frozen parts 
should be covered with moist compresses for the first forty-eight 



FREEZING 475 

hours and then dusted with boracic acid and encased in a thin layer 
of wool. 

If the trouble is only local — -a frozen ear or foot — -begin by rubbing 
the part with snow or ice and then with cold water and finally apply 
cold compresses, gradually raising their temperature until the circu- 
lation is restored. Subsequently cooling lotions may be employed 
to allay the inflammation. 

The frostbite of the feet so common in the trench fighting of the 
European war, resulting often in gangrene is not due so much to 
the cold as to interference with the circulation, the result of wearing 
soggy socks and shoes unchanged, perhaps, for days. 



PART II 

CHAPTER I 
TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY 

Tracheotomy is often performed in general practice as an opera- 
tion of the greatest urgency, and one should be prepared to do it 
anywhere, at any time, and, if necessary, with a pen-knife. Yet it is 
not so simple a procedure as one might infer. To do it properly and 
quickly, requires coolness, knowledge, and 
method. It is the measure of relief indicated 
in every case of laryngeal asphyxia, whether 
due to spasm of the larynx, edema following 
burns, injuries, or disease such as diphtheria 
or cancer; or to the presence of foreign bodies. 
In the case of diphtheria, intubation is always 
preferable to tracheotomy, but the necessary 
appliances may be lacking. The essential 
equipment for tracheotomy is a sharp pointed 
scalpel and a tracheotomy tube, and to these Fig. 359.— Tracheotomy 
as mere conveniences, may be added scissors, 
artery and dissecting forceps, tenacula, mouth-gag, and tongue 
forceps. 

The tracheotomy tube (Fig. 359) should be of simple construction, 
easy to introduce, and as large as the diameter of the trachea will 
admit. Treves furnishes the following table relative to the age of 
the patient and the diameter of the tube: 

AGE DIAMETER OF THE TUBE 

Under 18 months, 4 mm. 

iH to 2 years, 5 mm. 

2 to 4 years, 6 mm. 

4 to 8 years, 8 mm. 

8 to 12 years, 10 mm. 

12 to 15 years, 12 mm. 

Adults, 12 to 15 mm. 

477 




478 



TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY 



Every practitioner should have tubes of various sizes in his "arse- 
nal;" Senn recommends Trousseau's, while Lejars prefers those of 
Krishaber, because less likely to become occluded. 

Anesthesia is often unnecessary, owing to the condition of the pa- 
tient. Otherwise a few whiffs of chloroform should suffice. It need 
scarcely be said that under these circumstances, free use of the 
anesthetic will only hasten the fatality. 

The preparation of the field can be hastily but sufficiently done by 
painting with iodine. 




Fig. 360. — Locating the cricoid cartilage. (Veau.) 



The little patient's arms should be pinioned to its sides with a towel 
or sheet, it should be placed on its back with a cushion under its 
shoulders to drop the head backward and bring the trachea into 
bolder relief. 

Operation. — Stand at the right side of the patient; locate the hyoid 
bone, the thyroid prominence, the cricoid cartilage, and the sternal 
notch; and steady the trachea, holding the cricoid between the middle 
finger and the thumb of the left hand, while the index finger locates 
the middle line (Fig. 360). 

It is along the middle line that one must incise, and the aim is to 
divide the upper rings of the trachea and to avoid the thyroid isthmus 
(Fig. 361). 



TRACHEOTOMY 



479 



Make the incision from the index finger downward exactly in the 
middle line for 2 inches (Fig. 362). Incise rapidly with a single 
sweep of the knife. The left index finger in the upper angle of the 
wound hooks up the cricoid and still locates the middle line. Pay 
no attention to the bleeding, and without hesitation push the point 
of the bistoury through the upper ring and cut downward through 
the second and third if necessary. The air hisses through the 
opening. It is a moment of confusion, but one must keep cool. 

Insert the tube. Without changing its position, 
the left index finger presses the tracheal wound 
open and the right hand introduces the tube. 
It is held horizontally at first, until the point is 
well in the trachea, and then is carried upward 
in a curve until its beak corresponds to the 
lumen of the trachea (Fig. 363). The patient's 
gasps expel blood and perhaps false membrane, 
which the attendants must avoid inhaling. The 
tapes attached to the tube are fastened behind 
the neck. Apply artificial respiration if the 
patient's condition is not satisfactory. Let the 
air pass through a warm, moist compress until 
the temperature of the room can be regulated. 

As Veau points out, the operation may fail for 
several reasons, all within the control of the operator. The most 
frequent cause of failure is faulty introduction of the tube; it does 
not enter the tracheal canal, but is pushed down between the 
mucous membrane and the tracheal wall. These structures are 
loosely connected. The error is to be recognized by the absence 
of the characteristic sound of escaping air. 

The orifice is to be inspected, and, if too small, enlarged, before 
trying the second time to introduce the tube. 

Again, too much force in making the incision may result in wound- 
ing the posterior wall of the trachea. Excited operators have split 
the trachea its entire length, or wounded the vessels of the neck. 
There need be but little hemorrhage in the operation, if one but keeps 
in the middle line; and, as Senn says, that is the secret of success in 
performing the operation quickly and safely. 




Fig. 361. — Trache- 
otomy. Dotted lines 
represent the thyroid 
isthmus. {Veau.) 



480 



TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY 




Fig. 362. — Tracheotomy. Incision. (Veau.) 




Fig. 363. — Introducing the tracheotomy tube. (Veau.) 



TRACHEOTOMY FOR FOREIGN BODIES 481 

The operation may be varied somewhat, depending, of course, 
upon the conditions. The cricoid may be divided if necessary. In 
other cases, before cutting downward it may be necessary to draw 
downward the isthmus of the thyroid gland before enlarging the 
opening. 

In any case where time does not press, as when the tracheotomy is 
done preliminary to some other operation, the various steps may be 
carried out with more detail, the incision made by layers, vessels 
clamped, and the rings exposed, steadied with hoods and incised. 

The tracheotomy may be done below the isthmus of the thyroid, 
but the higher operation is much the easier anatomically, although 
the principle is the same. 

Tracheotomy for foreign bodies differs in some respects from the 
ordinary technic. Westmoreland, of Atlanta, who has had a large 
experience with this class of cases has recently emphasized some of 
these points (Amer. Jour, of Surg., Nov., 1909). 

The incision should vary in length depending upon the size and 
character of the foreign body. If the opening is sufficiently large 
the foreign body is easily expelled by the respiratory effort; usually 
the opening is made too small and the trachea is injured by the forci- 
ble extraction of the body. In the young the thyroid isthmus is 
usually in the way and should be divided between forceps and ligated. 
Even the thymus gland may intrude and is to be depressed with a 
narrow retractor. A tenaculum should not be employed lest it 
excite a troublesome bleeding. 

The incision in the trachea itself begins at the first ring. If 
asphyxia should occur in the course of the operation, the result of 
fixation of the object in the glottis, the operation should be rapidly 
finished, a tube or catheter passed into the trachea and the lung in- 
flated by blowing through the tube — -a great help in artificial respira- 
tion which soon resuscitates the asphyxiated child. 

Tracheotomy tubes are not to be used. Once the trachea is opened 
the body may be coughed out which a tube would prevent. The 
wound may be held open if necessary by silk threads passed through 
its edges. 

// the foreign body is expelled the trachea is to be sutured at once, 
employing a mattress suture of silk which is not to pass through the 
31 



482 TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY 



mucous membrane. Whether the tracheal wound is made air-tight 
or not is to be tested by filling the wound with normal salt solution 
and obstructing the nose and mouth which will force some bubbles 
through if not tight. The fascia, muscles and isthmus, and finally 
the skin are repaired. The dressing is held in place by adhesive 
strips. 

// inflammation exists, even though the body is expelled, do no 
suturing; cover the wound loosely with bichloride gauze to keep out 
cold air and to absorb the discharges. Change the dressing fre- 
quently. 

If th? foreign body is not expelled the protective dressing is to be 
applied which will not prevent the escape of the object if it should 
be coughed up later, and under this treatment the inflammation will 
probably rapidly subside. 

After-treatment. — The success of tracheotomy rests largely on the 
care with which the after-treatment is conducted. There is no 
operation, perhaps, in which care and skill are better rewarded and 
negligence and ignorance more severly punished. If the temperature 
of the room cannot be kept at close to 65 , the tube should be kept 
covered with a warm, moist compress. The wound must be kept 
clean. For the first few days, the inner tube must be removed and 
cleansed several times daily. This should be done rapidly, and the 
tube disinfected and oiled before being reintroduced. 

Morse (Post-operative Treatment, page 174) says, unless the 
cause of obstruction is a permanent one, it is often advisable to 
remove the tube after twenty-four to forty-eight hours; but the 
patient should be allowed to try breathing through the mouth before 
removing the tube, testing his capacity by stopping the cannula. 
In any event, he should be gradually accustomed to breathing 
through the mouth by plugging the canula. 

Morse advised that soup, milk, or broth should be given at first, 
if necessary through a nasal or esophageal tube, although this is not 
often required. Difficulty in swallowing is likely to occur on the 
third or fourth day, but encouragement will enable the patient to 
overcome this. Nutrient enemas are rarely necessary. 

Link, of Indianapolis, relates an experience (Medical Record, 
March 2, 1907) which illustrates at once the value of the operation, 



TRACHEOTOMY FOR LARYNGEAL EDEMA 483 

the improvisation of instruments to meet an emergency, and one of 
the rarer forms of suffocating edema. 

At midnight he was called to see a patient said to be choking to 
death and whom he supposed had an attack of asthma. He found 
the patient, a man weighing 250 pounds, cyanosed and laboring 
for breath. One hour previously, it seems, his throat had been 
lanced for the eleventh time in the course of a ten days' attack of 
tonsillitis. 

A hurried examination found the pharynx too tightly swollen to 
pass a finger. How much laryngeal edema there might be could 
only be guessed. Thinking to intubate past the swollen pharynx, 
Link used the only thing available, the vaginal tip from a hard- 
rubber syringe, bent at nearly a right angle. The attempt failed. 
While preparing for a local anesthesia to do a tracheotomy, the 
patient's neck was surrounded with iced cloths, but this seemed 
to aggravate the asphyxia; the patient became unconscious and 
ceased to breathe. 

The anesthesia was no longer necessary. All had fled but one 
woman, and while she held the patient's head, the doctor did a low 
tracheotomy. 

F He says, kneeling in front of the patient, who was in a sitting pos- 
ture, he incised the skin and deep fascia in the median line 2 inches 
above the sternal notch, working with his finger down to the bron- 
chial rings. With the finger as a guide, the knife was introduced, the 
trachea stabbed and cut slightly upward. A closed hemostat was 
then introduced and opened. Very little blood was lost. A female 
silver catheter from his pocket case was introduced and held in place 
by the assistant, 'while the doctor performed artificial respiration. 

The patient soon began to breathe, but his convulsive movements 
threatened the loss of the small tube in the throat. The hard-rubber 
vaginal syringe tip was brought into use again, whittled and inserted. 
The elbow shape fitted perfectly. In half an hour the patient asked 
to be put to bed, and breathing entirely through the tube, slept the 
first sleep for several nights. 

The edema declined as fast as it had arisen, and, within a few 
hours, the patient could breathe through the mouth when the tube 
was closed, and recovery was uneventful. 



4 8 4 



TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY 



LARYNGOTOMY 



As an emergency operation, this is most frequently done in an adult 
for cancer, but one need not wait until the patient is asphyxiated for 
there is nothing gained thereby. Therefore one may operate deliber- 
ately, for there is not the extreme urgency as with the infant. 

Local anesthesia may be sufficient. Define as before the inferior 
border of the thyroid cartilage and the upper border of the cricoid, 
between which is the crico-thyroid membrane which is to be incised 
(Fig. 364). In the middle line over the space, 
make a vertical incision an inch long. Catch 
the bleeding points and retract the lips of the 
wound. Carefully incise the fascia until these 
cartilages are exposed. Now incise the crico- 
thyroid membrane transversely and open into 
the larynx (Fig. 365). 

Introduce the tube as in tracheotomy. Re- 
move and cleanse the inner tube on the first two 
days and the large tube on the third day. 

Of course, if the operation is for cancer, it is 
merely palliative and the patient will continue 
slowly to die. If the operation is for edema of 
the larynx, the cause must be treated and the 
proper time finally to withdraw the tube deter- 
mined by the conditions. If the operation is for a foreign body, the 
wound may be sutured at once. 




Fig. 364. — Laryn- 
gotomy. Incision of 
crico-thyroid mem- 
brane. (Veau.) 



ESOPHAGOTOMY (Cervical Region) 

This is an operation only exceptionally of value fort he esopha- 
goscope will usually enable the foreign body to be removed without 
operation even after the ordinary maneuvers have failed (see Foreign 
Bodies). Nevertheless in the case of irregular bodies fixed in the 
lower cervical region it is preferable to open the esophagus rather 
than lacerate the mucosa in dragging the object out. A skiagraph 
will help to locate the body definitely preliminary to operation. 



ESOPHAGOTOMY 



48S 



Position. — Place the patient on his back with shoulders elevated 
and the neck resting on a sand-bag with head turned to the right. 

Incision. — Begin opposite the upper border of the thyroid cartilage 
and continue downward along the anterior border of the left sterno- 
mastoid for 3 or 4 inches, incising the skin, superficial fascia, and plat- 
ysma. Ligate the veins and draw the sterno-mastoid forward and 
the depressors of the hyoid downward (Fig. 366). The w T ound is thus 
enlarged and at the bottom is the layer of cervical fascia connecting 




Fig. 365. — Laryngotomy. Incision of the crico-thyroid membrane. (Veau.) 
It is better to cut transversely in order to avoid the crico-thyroid artery. 



the thyroid gland and the sheath of the large vessels. Incise it and 
again enlarge the wound by drawing forward the thyroid gland, 
trachea, and larynx, and backward, the great vessels in their sheaths. 

At this stage, in the bottom of the wound are the inferior thyroid, 
which must be ligated, and the recurrent laryngeal nerve, which 
should be drawn forward. 

The esophagus now appears as a red tube. To steady the esoph- 
agus and define its walls, an esophageal bougie may be inserted. 
The wall of the esophagus is raised with mouse-tooth forceps (Fig. 



486 



TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY 



367) and incised along its lateral wall. A suture is passed through 
each lip of the incision, that they may be readily retracted while the 
foreign body is located and removed, not always the easiest part 
of the task. 

The wound of the esophagus is repaired with sutures of catgut 
and the rest of the wound lightly packed with gauze until all danger 
of infection is passed. 




•• Slcrno-lfujr. 

St.-hyoid. 

OniQ-hyoid 

- Sternd-mo»$. 

^ ,■ ::••••' 
<' f 



Fig. 366. — Esophagotomy: exposing the infra-hyoid group of muscles. (Lenormaut.) 



As Bryant says, ordinarily the operation of cervical esophagotomy 
is not a perplexing procedure, but when the neck is short and fat, 
the vessels and thyroid gland enlarged, the detection and removal 
of the foreign body difficult, or the patient exhausted, the operation 
often taxes the patience and fortitude of the surgeon. 

After-treatment. — The patient must be kept in bed with shoulders 



ESOPHAGOTOMY 



487 



raised. Nourishment should be given at first by enemata, and later, 
if necessary, by the esophageal tube. 

Nassau reports a case illustrating the subject. A child swallowed 
a five-cent piece and thereafter could take only liquid foods. "X- 
ray" examination showed the coin lodged at 
the level of the suprasternal notch or just 
above. 

Removal was attempted with forceps but 
without success, although the coin could be 
felt. An esophagotomy was done. The opera- 
tion was completed in fourteen minutes. No 
vessels require ligation. The esophagus was 
not sutured and the superficial wound was 
closed with drainage. There was no leakage 
and the child made an uneventful recovery. 
Nassau does not regard esophagotomy as a 
serious operation, but believes it should not 
be considered until efforts at extraction have failed. 




Fig. 367. — Esophagot- 
omy. Final incision. 
(Bryant.) 






CHAPTER II 

URGENT THORACOTOMY. REPAIR OF INJURY TO THE 

LUNGS. REPAIR OF INJURY TO THE PERICARDIUM ; 

OF INJURY TO THE HEART. PUNCTURE OF 

THE PERICARDIUM 

As has been indicated elsewhere (see Injuries of the Thorax), 
urgent intervention for injuries of the thorax is a form of operative 
procedure at this present time with but a limited field. Whatever 
may be the apparent gravity of the case, it is far from being the rule 
to operate, for such operations require trained assistants, a special 
equipment, and a superior surgical skill. Of necessity, then, in 
general practice, the treatment must, generally speaking, be con- 
servative: that is to say, cleansing of the external wound with en- 
largement and trimming up if necessary, reunion and aseptic oc- 
clusion, firm bandaging of the thorax, and an absolute quiet in bed. 
These measures along with stimulation with caffein and camphor- 
ated oil and normal salt solution, represent the elements of treat- 
ment which are within the scope of all. 

But there are cases so manifestly fatal without operation that, as 
Lejars says, one cannot evade the question, "operate or let die?" 

Grave rupture of the lung indicated by an immediate flooding of 
the pleural cavity, followed by urgent symptoms of asphyxia and 
syncope, is the signal for immediate operation. Again, repeated 
attacks of secondary hemorrhage call for operation. 

URGENT THORACOTOMY 

The technic of this operation can be exactly defined only in a gen- 
eral way and will need to be modified to suit the individual case. 

Lejars insists that the opening must be large, that anything less 
will be a disappointment and the operation might as well not be 
undertaken. 

488 



THORACOTOMY 489 

The operation may proceed in one or two ways: (i) by a permanent 
resection of the ribs necessary to be removed, or (2) by temporary 
resection with the formation of a thoracic flap. 

(1) Make a U-shaped incision forming a flap with its base posterior, 
and of which the two arms run parallel with the ribs and are wide 
enough apart to include at least three ribs. 

The incision reaches to the ribs. Rapidly dissect up this musculo- 
cutaneous flap, exposing the ribs and intercostal muscles. With 
the flap held out of the way, begin the resection of the ribs by incising 
the periosteum of the lowest rib along its middle line, the full length 
of the exposed part. Denude the rib with the rugine. Take special 
care in the denudation along the lower border that the artery and 
nerve removed with the periosteum are not wounded. Divide the 
inner and the outer end of the denuded segment. (See Operation 
for Empyema.) Resect the other ribs exposed in the same manner. 

Raise the muscuto-pleural flap. Begin by dividing the upper bor- 
der; then the lower border; and finally the anterior border, catching 
each intercostal artery as cut. When this flap is lifted the lung 
is exposed. 

This procedure has the advantage that it can be rapidly carried 
out; the disadvantage, that it permanently' sacrifices a part of the 
bony wall of the chest, but that is a small matter in the face of such 
emergencies. 

(2) A thoracic flap may be formed. Make the same "U"-shaped 
incision and expose the ribs as in the preceding operation. Each 
costal segment is then denuded of periosteum at either end suffi- 
ciently for the passage of the bone-cutting forceps. In this manner 
each rib is divided at each end. 

Next carefully divide the intercostal muscle parallel with, and 
above, the first segment, and lift the anterior end of this rib, and 
begin the separation of the pleura. 

Work along the front at first, dividing the intercostal muscles and 
arteries and ligating as necessary. The liberation of the flap along 
the lower border next follows and, as the musculo-osseous flap is 
more elevated, the separation of the pleura is more and more 
facilitated. 

Finally the flap is freed and turned back and the pleura is left 



490 URGENT THORACOTOMY 

bared. The pleura is next divided and the wounded lung is now 
freely exposed. 

Wipe out the clots and search for the bleeding surface. If neces- 
sary a hand may be slipped under the base of the lung pulling it 
forward for inspection. 

Repair the lung. The ideal method is by suture, employing a 
No. i or 2 silk thread and passing it through the parenchyma with 
a round curved needle. If this is not possible tamponade is the next 
resort. If a border is lacerated and projecting it may be ligated 
en masse and resected. 

Whether or not drainage is employed depends upon the amount 
of^oozing and the probabilities of infection. If infection subse- 
quently develops, the infected area is to be opened and drained as 
any other empyema. 

REPAIR OF INJURIES TO PERICARDIUM AND HEART 

The general practitioner does not see many injuries to the heart. 
Gunshot wounds are, of course, usually immediately fatal; so that 
the form of cardiac injury most likely to present itself for treatment is 
a stab wound. Occasionally the heart is lacerated by a broken rib. 
The sudden death from cardiac wounds may occur in several ways. 
It may occur from syncope arising from the pressure of the blood 
within the pericardium; or the heart may be unable to contract be- 
cause of its divided fibers and cerebral anemia follows; or shock or 
pulmonary edema may be the immediate cause of death. 

Even if death does not immediately occur, hemorrhage and in- 
fection may later provoke a fatal issue (see Injuries to the Thorax, 
page no). 

The treatment of traumatisms of the heart and pericardium has 
three ends in view; to combat shock, to control hemorrhage, and to 
prevent infection. 

Keep the patient absolutely quiet, lower the head, apply artificial 
heat, give morphine in small doses {% gr.) hypodermically; and, 
if there is an open wound in the chest, disinfect and dress asepti- 
cally, but do not operate merely to disinfect. 



THORACOTOMY 



491 



If the heart is injured sufficiently to bleed, operate. The sole 
indication, then, for operative treatment is hemorrhage. 

The patient will probably die even if operated upon, but he will 
most certainly die without the operation; so that it is our duty to 
give him the additional chance which intervention offers. 




Fig. 368.— Forming the costal flap. The three ribs in the flap are divided near the sternum . 
and the upper and lower ribs divided at the outer limit of the flap. The middle rib to 
be fractured by raising the flap. 



If the wound seems likely to have reached the heart; if there is 
bleeding; if there is pain and precordial oppression; if there are fre- 
quent attacks of syncope; if there are signs of increase of fluids 
about the heart; then one is justified in believing that the heart 
has been wounded sufficiently to produce hemorrhage and must 
prepare immediately for the operation. There must be no delay. 



492 



URGENT THORACOTOMY 



Nevertheless in the haste nothing in the matter of asepsis must be 
omitted. 

The field may be hurriedly and yet sufficiently prepared by scrub- 
bing with alcohol followed by iodine. There is little use to stop 
the bleeding if the patient is to die later from sepsis and that he is 
certain to do if a faulty technic is followed. 







:W-^ : l 



Fig. 369. — Costal flap reflected. Pleura retracted. Edges of pericardial wound held 

in forceps and heart wound exposed. 

General Anesthesia. — Ether should be employed if the patient's 
condition will permit. 

The operation proposes to make a thoracic flap, to open the 
pericardium and expose the heart, and to repair the injury. 
There is no operation that requires more decision, courage, and 
self-control. 

Incision. — Begin in the third intercostal space just in front of the 



EXPOSING THE HEART 



493 



anterior axillary border and cut inward to the border of the sternum 
abruptly curving there and following the sternal border downward 
to the sixth space; again abruptly curving and following that space 
outward (Fig. 368). These incisions expose the ribs and intercostal 
muscles. 




Fig. 370. — Heart supported in palm of hand preparatory to suturing. (Ajter Lejars.) 

Formation of the Flap. — Divide the fourth, fifth, and sixth carti- 
lages near the sternum and also the intercostal muscles, along the 
line of the original incision. 

At the lower outer angle of the incision, expose the sixth rib by 
pulling the tissues upward. Incise the periosteum over its external 



494 



URGENT THORACOTOMY 



surface and with the rugine free the rib of periosteum and divide it. 
At the upper outer angle expose the fourth rib, free it of periosteum, 
and with the costotome or a bone-cutting forceps, divide it in the 
same way. The flap is now attached only by the fifth rib which is 
to be fractured. Raise the sternal end of the flap with the left hand 
and press on the fifth rib with the right hand and with a little force 
the rib is broken in the line of section of the other two ribs. 

The flap is now gradually raised as its adhesions to the subjacent 
structures are freed, and the pleura is exposed. 

If there is a wound in the pleura, enlarging it, the pericardium may 
be reached; otherwise proceed to the liberation and retraction of the 



v 




xtc. 




#.tt. 



Fig. 371. — Suture of wound of heart. 



Fig. 372. — Suture of heart completed. 



pleura. With a grooved director, liberate the fibrous attachments 
of the triangularis sterni to the posterior surface of the sternum, 
which at the same time liberates the pleura. With the fingers, draw 
outward the free border of the pleura with its covering, the triangu- 
laris sterni (Fig. 369). In this manner is the pericardium exposed. 
The assistant holds the pleura with a retractor. 

Incision of the Pericardium. — Enlarge the wound in the pericardium 
and in that manner expose the heart. Retract the edges of the peri- 
cardial wounds with forceps. Locate the wound in the heart. Slip 
the left hand under the apex and pass the first suture, and the heart 
may be thereafter steadied by traction on the threads of the first suture 
(Fig. 37o). 






SUTURING THE HEART 495 

Suture the wound in the heart. Use either interrupted or continuous 
suture of catgut. There is no particular advantage in passing the 
suture in diastole. Pass them deeply, but not to the endocardium 
(Figs. 371, 372). 

Now wipe out the pericardial cavity with sterile compresses and 
repair the pericardium by continuous catgut suture. Next, wipe out 
the adjacent portion of the pleural cavity, repair any part of the lung 
that may be injured and repair the pleura without drainage. Finally, 
replace the thoracic flaps, and suture. It is generally wise to excise 
the tissues along the track of the wound. 

No drainage is to be employed except under these circumstances: 
if the case was operated on late and there is great probability of 
infection, it is better to leave drainage in the pleural wound, pro- 
jecting from the thorax at the lower angle of the skin wound; if there 
is much oozing, it is better to leave a wick of gauze in the pleural 
wound. 

A case of successful suture by Gibbon, of Jefferson Medical 
College, illustrates the subject (Jour. American Medical Assn., Feb. 
to, 1906). Patient, aged thirty-eight, healthy colored man. Stab 
wound of chest, a few moments after which he fell unconscious. An 
hour later at the hospital his condition was very grave: unconscious, 
cyanosed, pupils dilated, skin cold and moist, respiration rapid and 
shallow. No pulse in the peripheral vessels and the heart sounds 
were distant, rapid, and irregular. 

Vigorous stimulation was employed with morphine and atropine 
and his condition slightly improved. Operation about one and one- 
half hours after the injury. Only a small quantity of ether required. 

The fourth costal cartilage was found and divided and the entire 
cartilage and a part of the rib was removed. The pericardium 
was explored and a wound located which would only admit tip of in- 
dex finger. This pericardial wound was enlarged and the sac emp- 
tied of clots and liquid blood. It began rapidly to fill again. Two 
fingers passed under the heart lifted it up into the pericardial open- 
ing and with rapid sponging, the wound was located. It was 
situated in the right ventricle near the auriculo-ventricular groove. 
It bled freely, controlled by pressure; was about % inch in length. 
The wound in the endocardium was about one-half as long. 



496 URGENT THORACOTOMY 

A traction suture of chromicized catgut was passed through both 
edges and by that means the heart was held in position, while four 
other sutures were passed and no effort was made to avoid the en- 
docardium. A small gauze drainage was applied to the line of 
sutures and brought out through the pericardial wound which was 
not sutured. 

During the subsequent twelve hours there was enough oozing 
to require a change of dressing. His general condition was fairly- 
good. The second day his condition was alarming; respirations 62. 
The gauze was found to be interfering with drainage and removed. 
The respirations fell to 38 in a short time. 

Large quantities of salt solution were given by rectum. Liquid 
food on second day. The dressings were changed every other day. 
Six days after the operation the skin wound was sutured almost com- 
pletely, the wound in the pericardium being practically healed. 
In six weeks he returned to work completely recovered, with heart's 
action regular and normal. 

Gibbon does not advise an osteo-plastic flap unless a pleural wound 
is demonstrated, believing it best to excise as much of the sternum 
or cartilage or rib as may be necessary to give free access. He em- 
phasizes the value of the traction suture, and advises the repair of 
the pericardial wound without drainage, but would always drain the 
external wound. 

Travers (Lancet, Sept., 1906) operated upon a case in which the 
patient was impaled upon a spike fence. The right ventricle was 
torn, the spike penetrating the sternum to reach it. The wound 
in the heart was closed by twenty sutures. The patient did very well 
up to the eleventh day, when he died from heart failure, due to the 
pressure of a slowly forming clot. 

Travers notes that the suturing seemed to stimulate the flagging 
heart. 

Stewart, among the first in the United States to suture the heart 
successfully, turned the musculo- cutaneous flap to the left and the 
thoracic flap to the right, fracturing the cartilages near the base of the 
sternum. 

The pericardial wound was enlarged in the axis of the heart. The 
heart wound, produced by a stab with a long, rusty pen-knife, involved 









SUTURING THE HEART 497 

the thickness of the left anterior ventricular wall, ran parallel with the 
axis of the heart, and was about % i nc h * n length, was larger than 
either the skin, pleural, or pericardial wound. The heart bled freely 
and continuously, and resembled a mere quivering mass of muscle. 

The wound was closed with a continuous silk suture, the pericardial 
cavity cleansed and the sac sutured with silk. A gauze drain was 
left at the lower angle. The pleural cavity was cleansed and irri- 
gated with salt solution. The thoracic flaps were sutured with silk- 
worm-gut and a gauze drain left also in the pleural cavity. 

During the operation, which lasted about forty-five minutes, 
24 ounces of salt solution and adrenalin were injected, and strychnin 
and atrophin given hypodermically. 

Some infection followed, and by the eighth day, the temperature 
was 103 , pulse 150, and respiration 50. From that time, the symp- 
toms of sepsis gradually declined until at the end of three weeks, these 
conditions were practically normal; at the end of the fifth week, the 
patient was out of bed. 

Stewart, discussing the operation (American Journal Med. Sci- 
ences, Sept., 1904), notes that the size of the heart wound cannot be 
predicted from the external wound; and concludes that the only safe 
procedure in doubtful cases is to enlarge the wound and ascertain if it 
penetrates the chest wall; and if there be symptoms of hemorrhage — ■ 
of heart tamponade — -operate. 

In all of these cases already mentioned, it was the ventricle which 
required repair. Peck, of New York, describes a case in which it was 
necessary to suture the auricle (Annals of Surgery, July, 1909). 

The patient, a colored girl twenty-four years of age, was brought 
to the hospital suffering from a stab wound over the third costal carti- 
lage at the left border of the sternum. Her condition was grave: 
no radial pulse; the heart sounds could not be heard; respiration faint 
and shallow, and the extremities cold; operation begun about forty- 
. six minutes after the receipt of the injury. 

A quadrangular flap of the soft parts with base external was dis- 
sected back. The third, fourth, fifth and sixth cartilages were di- 
vided at the sternal junction, and the third, fourth, and fifth ribs near 
the costo-chondral junction, and the flap turned out and the internal 
mammary ligated above and below. The pericardial wound was 
32 



498 URGENT THORACOTOMY 

near the border of the sternum, a part of which was resected with 
rongeur forceps to give a better view. The tense pericardium was 
incised and the clots emptied out, whereupon the radial pulse could 
be felt. 

The bleeding seemed to come from the upper part of the cavity but 
the rapidly beating heart, churning the free blood, made it impossible 
to locate the wound until a transverse cut in the sac gave a better 
exposure. 

Lifting the heart forward and slightly rotating it to the left, a 
wound of the right auricle was brought into view. With each systole 
a stream of dark blood spouted 2 or 3 inches. Four sutures of 
chromicized catgut passed on a curved intestinal needle controlled 
the bleeding. The pericardium was cleansed, close without drainage 
with continuous chromic catgut suture. The cartilaginous flap was 
carefully sutured with No. 3 chromicized gut and the soft parts with 
catgut and silkworm-gut. No drainage was used. The operation 
lasted sixty-five minutes, during which time 1900 C. of normal salt 
solution was given intravenously. For the first six or seven days 
there were signs of mild pleurisy and the temperature ranged from 
100 to 102.8, pulse 116 to 136; but, at the end of two weeks, these 
were practically normal, and at the end of another week, she was dis- 
charged, quite well. 

It will be observed that the incision and flap formation differed 
with each operation, no one method can be insisted upon to the ex- 
clusion of all others. 

PUNCTURE OF THE PERICARDIUM 

Puncture of the pericardium — paracentesis pericardii — -is indicated 
in those cases of hemo-pericardium and serous effusion in which 
the accumulating fluids dangerously interfere with the functions of 
the heart. The physical signs and the symptoms point to the nature 
of the difficulty. The symptoms may be overlooked in those which 
pertain to the primary infection. The patient breathes with diffi- 
culty and complains of pain and tenderness over the heart, the pain 
radiating down the left arm or the epigastrium; the temperature is 
variable; there is leucocytosis. 



PUNCTURE OF THE PERICARDIUM 



499 



The physical signs are significant: The pulse is weak and rapid, 
there is often precordial bulging; the dullness of the heart area is 
increased the heart sounds are faint; and in some cases the first rib 
is pushed away from the clavicle (Ewart's sign). The exploratory 
puncture will confirm the diagnosis. It is not more frequently 
done because of the instinctive fear that one may wound the heart; 
indeed there are three structures which may be wounded with serious 




Fig. 373- — Puncture of the pericardium and pericardiotomy.; vertical lines, represent the 
anterior border of pleura and lung. The • represents sites of puncture. ^™, line of 
incision for, and portion of rib resected in; pericardiotomy. 



consequences; the heart, the pleura, and the internal mammary 
artery. 

The puncture may be made near the sternum to the inside of the 
internal mammary; it may be made to the outside of the internal 
mammary, between it and the line of the lung. The latter is perhaps 
the better (Fig. 373). 

The point of entrance of the needle is in the fifth left intercostal 
space, 6 cm. from the sternal border. Use a small trocar or an as- 



500 URGENT THORACOTOMY 

pirator. Cleanse the field thoroughly. Put the patient in a half 
reclining position on his bed and mark with the left index finger the 
site of the puncture. 

Direct the needle obliquely downward and inward and do not 
penetrate deeper than 2.5 cm., holding the needle so as to regulate 
its progress. 

As the pericardium empties itself, gradually elevate the trocar so 
as not to wound the heart. 

PURULENT PERICARDITIS. PERICARDIOTOMY 

If in addition to the physical signs pertaining to effusion, there are 
edema of the chest wall and the symptoms of sepsis it is almost 
certain a purulent pericarditis is to be dealt with and if the explora- 
tory puncture demonstrates the presence of pus, the only rational 
treatment is drainage, unless the patient is moribund. To incise 
and empty the pericardium is the only procedure that offers any 
hope of permanent relief. 

Operation. — Begin by locating the attachment of the fifth costal 
cartilage and the middle of the sternum. 

Incision, — From the middle of the sternum horizontally outward 
over the center of the fifth cartilage on the left side, to the costo- 
chondral junction. Deepen the incision so as to divide all the soft 
parts down to the cartilage. Strip back the covering of the cartilage 
with the rugine (Fig. 373). 

Resect the cartilage at its sternal junction and, gently lifting up, 
gradually detach its coverings behind out to the junction of the rib. 
Here it may be fractured or permanently resected. Dividing their 
sternal attachments, retract the intercostal muscles with the arteries 
in the space opened up and thus expose the pleura. 

Detach the pleura by loosening the sternal attachments of the tri- 
angularis which allows the pleura to be drawn outward. This 
should be done with the finger passed under the sternum and hooked 
around the border of the pleural sac. The pericardial sac is now 
exposed. 

Incise the pericardium, first catching up a fold between two forceps, 



PERICARDIOTOMY 501 

and dividing it with scissors. If possible, the edges of the pericardial 
wound should be stitched to the margin of the skin wound. 

Insert gauze drainage: A rubber tube is too likely to irritate the 
heart. This operation is often followed by recovery without any 
impairment of the heart's action. 



CHAPTER III 

EMPYEMA— PURULENT PLEURISY 

Various bacteria may attack the pleura, most frequently they are 
the pneumococcus, the streptococcus, the staphylococcus, the 
bacillus tuberculosis, or the bacillus communi coli. 

The pneumococcus is usually present in the empyema of childhood. 
Be on your guard for empyema especially in whooping-cough. 

The clinical history and the prognosis vary in different forms of 
the disease and are directly dependent upon the form of the infection. 

But, whatever the pyogenic agent, when pus has once formed in 
the pleural cavity, it seeks for an outlet in various directions. It 
may rupture into a bronchus and escape by the mouth, and, under 
these circumstances, pneumothorax may ensue; it may perforate 
the chest wall, manifesting itself as an external abscess of various 
forms; it may open into the pericardium, esophagus, or stomach. 

In every case, the longer relief is delayed, the greater the proba- 
bility that the lung will be permanently collapsed or bound down 
by adhesions. Finally, in some degree, there are always the evil 
results of sepsis. There is every reason, then, when pus is known to 
exist in the pleural cavity, to drain without delay. 

The diagnosis rests upon the history of the case (remembering that 
this history will vary with the form of infection), upon the pain, the 
constitutional symptoms which are those of sepsis generally, and 
upon the physical signs. These are: distention of the thorax ac- 
companied perhaps by edema of the chest wall; flatness on percussion 
and evident displacement of neighboring organs; absence of the 
vesicular murmur, and the presence of bronchial breathing. 

Taylor, of Springfield (Illinois Med. Jour., 1907), attributes the 
most frequent source of error in diagnosis to a misconception of the 
position assumed by the exudate. 

Physicians are observed trying to establish a horizontal line for 

502 



EXPLORATORY PUNCTURE 



503 



the exudate with the patient in the sitting posture, under the im- 
pression that the fluid will follow the influence of gravity. But this 
is the exception rather than the rule. The dullness is usually higher 
posteriorly. The "S "-shaped line of Ellis, if present at all, is so 
variable from day to day as to be of minor importance. Taylor 
remarks further that the character of the fluid is often a matter of 
doubt. Chills and variable temperature point to pus, although he 




Fig. 374- — Puncture of the pleura. (Lejars.) 

has seen patients recovering from pneumonia who had none of these 
symptoms and yet carried around three pints of pus in the pleural 
cavity. 

Most of the signs and symptoms may occur as well with pieurisy 
with effusion, and it is only by exploratory puncture that the matter 
may be definitely determined. 

Exploratory puncture, then, is the court of final resort and must 
always be employed before deciding upon the form of treatment. 



5°4 



EMPYEMA — PURULENT PLEURISY 



PUNCTURE OF THE PLEURA 



Let the patient lie on the sound side with his shoulders elevated 
and the arm of the affected side extended above the head, the effect 
of which is to widen the intercostal spaces. Locate, for example, a 
point in the axillary line and the sixth intercostal space. Freeze the 
skin with ethyl chloride or inject a little cocaine at the site of punc- 
ture. Press a finger into the intercostal space and locate the lower 
border of the rib. With the finger as guide enter the needle so as to 
avoid the rib and thrust it inward and slightly upward. One can 
readily determine whether it has reached the pleural cavity by the 
degree of resistance. Enough fluid, whether pus 
or serum, will escape through the aspirating needle 
to make its presence certain; but in order to draw 
off any quantity an aspirator, of which Potain's 
(Fig. 374) is the best type, must be attached. A 
serous pleuritic effusion is relieved by aspiration. 
Sometimes removal of even a small quantity will 
start absorption in a case of long standing. If the 
fluid is pus, the subsequent course of events is 
quite different. 

As has been said, every purulent pleurisy must 
be opened as soon as possible, must be opened 
freely and at its lower point. 

In the case of a child, it suffices usually to in- 
cise the intercostal space in order to perfect a 
cure. In the case of the adult, it is necessary to resect a rib for 
adequate drainage, and even then, the patient may shortly die or 
retain a chronic sinus. These possibilities should always be ex- 
plained before the operation, necessary but disagreeable, is under- 
taken. 

Site of the Incision. — The cavity must be opened where it will drain 
best in the recumbent position. The lowest level of the abscess can 
be determined only by exploratory puncture; any other method is 
useless. Having already confirmed the diagnosis by puncture, now 
at the beginning of the operation, make another exploratory punc- 
ture in the space next lower. If pus is found there, puncture again 




Fig. 375- — Em- 
pyema: Relation of 
the pus cavity to 
the chest wall and 
lung. (Veau.) 



INCISION OF THE PLEURA 505 

in the space below, and so on until no pus is found. The last punc- 
ture producing pus will be the site of the incision. 

Anatomy (Fig. 375). — -The aim will be to incise parallel with the 
rib. In going through the structures of the intercostal space, re- 
member that the vessels and nerve lie in or near the groove in the 
lower border of the rib. Incising any space, therefore, keep close 
to the lower line of the space, keep near the upper border of the rib 
forming the lower boundary of the space. If a rib is to be resected, 
it should be denuded of its periosteum, which is loosely attached and 
on that account easily stripped off. 

EMPYEMA IN THE CASE OF A CHILD 

In the case of a child, simple incision of the pleura will suffice. 
Under general anesthesia, if the condition of the patient will permit, 
make an incision 3 or 4 inches long, parallel with the ribs. 
The incision traverses the skin, and beneath it a cellular layer, often 
edematous. Next divide the muscles, letting the rib serve as a resist- 




Fig. 376.— Incision of the pleura without resection of a rib. {Schwartz,) 

ing plane. In front they are thin (pectoralis major) ; behind, thicker 
(latissimus dorsi and serratus magnus). Divide them at a single 
stroke and without concern. A small artery may need to be clamped. 
Having exposed the rib (Fig. 376), retract the upper lip of the 
wound and locate the upper border of the rib; below, it bounds the 
space about to be penetrated. Following this border, incise layer 
by layer, the intercostal muscles. There is never any serious hemor- 
rhage. As you approach the pleura, be prepared for a sudden spurt 
of pus, and, when the pus flows, it is evident the pleura is opened. 
Enlarge the opening, using the left index finger as a guide. Incline 
the^patient so that the cavity may be entirely emptied. Fix the 
drainage-tube (Fig. 382). 



506 EMPYEMA — PURULENT PLEURISY 

EMPYFMA IN THE CASE OF AN ADULT 

In the case of empyema in an adult, it is usually necessary to resect 
a rib. One needs a bone-cutting forceps or a costotome and a curved 
periosteal elevator or rugine in addition to the ordinary instruments. 




Fig. 377. — Incision of the costal periosteum. (Veau.) 

Local anesthesia is preferable and with a little patience will be 
made to serve. Having determined the line of the incision inject 
with novocain, intradermically. Next infiltrate the subcutaneous 




Fig. 378.— Uncovering the posterior surface of the rib with rugine. (Schwartz.) 

tissues along the same line. Usually after a wait of five minutes the 
skin and fascias may be divided without pain. 

An injection is next made in the periosteum and the tissues ad- 
jacent to the site to be sectioned. With the timorous, ether may be 
necessary but it can never be considered safe in such conditions. 



RESECTION OF THE RIB 



S07 



Having determined, then, the site of incision by exploratory 
puncture, incise the skin and muscles as in the case of a child. The 




Fig. 379. — Section of the rib. (Schwartz.) 

length of the incision will equal four fingers' breadth. When the 
rib is exposed, divide its periosteum in the middle line (Fig. 377). 

The denudation of the rib is an important step. With the rugine 
or curved periosteal elevator, uncover the upper half of the external 
surface of the rib first and then the lower half, keeping very close to 




Fig. 380. — Section of the rib. (Schwartz.) 

the rib as you reach the lower border, so as not to wound the inter- 
costal vessels or nerve, which are closely attached to the periosteum 
and are removed with it. Finally, uncover the deep surface of the 
rib. Carefully slip the elevator upward between the bone and its 
periosteum, which is loosely attached (Fig. 378). Carry the elevator 
to one end of the section and then to the other and the part of the 
rib to be removed is thus entirely freed from its periosteal 
attachment. 



5o8 



EMPYEMA — PURULENT PLEURISY 



Divide the rib. Introduce one blade of a bone forceps or costotome 
under one end of the section to be removed and divide it (Fig. 379). 




Fig. 381, — Rib removed, pleura incised. (Veau.) 

Then divide the other end (Fig. 380). The bone removed should be 
2H to 3 inches long. .The stumps should not project beyond the 
limit of the flesh wound, else necrosis is favored. 

Incise the pleura. With the rib removed, the periosteum remains 
attached to the pleura and this periosteal layer is incised along its 




Fig. 382. — Drainage of the pleural cavity. {Veau.) 



middle (Fig. 381), and the pleura is divided at the same time. Be 
on your guard, when making the incision, for a spurt of pus. 

Empty and drain the cavity. Incline the patient to one side and 
instruct him to cough. The pus pours out, often offensively fetid. 
Take plenty of time. Finally, wipe out the cavity with sterile gauze. 
Irrigation is usually inadvisable; but, if used, employ only warm, 
sterile water, salt solution, or a weak solution of peroxide. The 
stronger antiseptics are dangerous. Do not suture the wound except 
to cover over the projecting end of the divided rib. The difficulty 
is to keep the wound open. 



DRAINAGE 509 

Drainage must never be neglected. Employ two large and long 
tubes placed in different directions and anchor with safety-pins (Fig. 
382) or by a suture, else they may be lost in the abscess cavity. 

Dressing. — This is important. Pack moist sterile or boracic 
gauze all around the tubes, between the lips of the wound. Apply 
an ample dressing of absorbent cotton, which covers half the thorax, 
and hold all in place with a large flannel bandage maintained by 
suspenders. Let the patient occupy the half-sitting position, in- 
clined toward the affected side and supported by pillows at the 
back. 

Subsequent Care. — After a few hours, change the dressing, which is 
usually saturated, but do not disturb the drains. Change the dress- 
ing twice daily until the discharge diminishes and about the third 
day withdraw, cleanse, and replace the tubes in the same place and to 
the same depth; else look for trouble, if you fail to accomplish this. 

Do not irrigate while making these dressings, unless the discharge 
has persisted undiminished for a week and continues fetid, when it is 
best to use a sterile wash of salt solution or dilute peroxide, which 
is to be injected under very slight pressure. 

The end results vary with the nature of the infection. 

(1) The meta-pneumonic pleurisy of children is usually cured. 
About the fifteenth day, smaller tubes may be used and are gradually 
to be shortened as granulation proceeds. In the fortunate case, the 
opening will close in something like two months. 

(2) In tubercular pleurisy with secondary infection, cure scarcely 
ever takes place. The patient will probably die in a few months of 
amyloid degeneration. Even if the patient does not die soon, the 
suppuration shows little tendency to yield. In these cases with per- 
sistent sinus, the bismuth paste injection often hastens a cure. 

(3) Streptococcic or staphylococcic pleurisy: The patient may go 
on to death or else recovers with persistent sinus. Keep the orifice 
open, for if the pus is allowed to accumulate, it will be necessary to 
operate again. Keep watch on the functions of the kidney and 
liver. Remember the frequency of metastatic abscess, as of the 
brain, for example. 

After two to four months, the case may be referred to a specialist 
for a plastic operation. 



CHAPTER IV 

URGENT CRANIECTOMY: TREPHINING 

FRACTURE OF VAULT OF THE SKULL 

There are two conditions which may accompany fracture of the 
skull, singly or together, either of which demands immediate relief. 
(See Fracture of the Skull.) 

(A) The depressed fragments have contused and lacerated the 
brain; consciousness was immediately lost and was not regained. 
Under these circumstances, the fragments must be elevated without 
delay. 

(B) Hemorrhage has occurred within the cranial cavity and the 
clot compresses the brain. In this case, there is a "free interval." 
The patieDt regains consciousness and, perhaps, for a time — -two to 
twenty-four hours — -appears not to be seriously injured, but little by 
little the signs of "compression" develop, namely: restlessness, dull- 
ness, stupor, coma; normal pulse at first, but which finally grows slow, 
full and bounding; and slow and stertorous breathing. Delay is 
dangerous. The clot must be removed and the hemorrhage checked. 

Nearly always it is the middle meningeal which is at fault. There 
is in consequence an extradural hematoma. Once in a while, however, 
the bleeding will be found to proceed from a ruptured sinus or from 
the pial arteries and there exists at the same time an injury to the 
brain substance. There is, in this case, an intradural or intracerebral 
hematoma. 

Whatever the form of compression, one is compelled to operate, 
but he must first get the anatomy of the middle meningeal artery 
clearly in mind. 

The middle meningeal, a branch of the internal maxillary, is the size of the 
radial, entering the cranial cavity at the base of the skull, through the foramen 
spinosum. It is embedded in the dura and grooves the inner surface of the skull. 

Above the level of the zygoma, the artery divides. The posterior branch 

5io 



TREPHINING 



5" 



the smaller, is directed upward and backward, and the anterior branch (Fig. 
383), the more important, ascends vertically to the fronto-parietal suture ; 
which it follows upward, passing a little posterior to it. As it reaches this suture, 
it gives off constantly a posterior branch. The anterior branch is accompanied 
by veins which occasionally assume the importance of a sinus. 

The directions for trephining over the middle meningeal are quite definite, 
but usually unnecessary to regard in emergency surgery, for it is a mistake 
not to follow the exterior indications and guides furnished by the traumatism. 
Still one should be able to locate these points readily. 

Two horizontal and two vertical lines are employed to locate the paths of the 
two branches of the middle meningeal. Draw the first (A) from the inferior 
border of the orbit along the zygoma to the external meatus. Draw the second 
(B) from the upper border of the orbit back- 
ward, and parallel with the first, ending be- 
yond the line of the mastoid. To locate the 
path of the anterior branch of the middle 
meningeal, draw a perpendicular line from A 
upward from a point corresponding to the 
middle of zygoma; and where it cuts B is 
the point most advantageous for exposing 
the anterior branch. This vertical line is 
about two inches in length or approximately 
equal to the length of the last two joints of 
the index finger. To locate the track of the 
posterior branch : From the apex of the mas- 
toid, draw a second vertical line upward; its 
point of junction with B indicates the path 
of the posterior branch. These lines may be marked off on the skin by tincture 
of iodine. 




Fig. 383. — Outline of the middle 
meningeal artery. (Veau after 
Cuneo.) 



Operation. — -Provide, besides the ordinary instruments, Rongeur 
forceps, a mallet and chisel, or a trephine. Carefully shave the half 
of the head corresponding to the traumatism or, even better, the 
whole head. Sterilize the field. Scrub with soap and water, fol- 
lowed by ether, which in turn is followed by bichloride solution. 
There must be no relaxation in the disinfection, whether exploration 
is to be extensive or not, for asepsis is the best means of preventing 
a hernia of the brain. 

General Anesthesia. — -Often the sensibility is so benumbed, the 
patient so depressed, that anesthesia is both unnecessary and danger- 
ous. Chloroform is generally best for brain surgery, but ether is 
safer in these urgent cases with much shock. 



Si2 



URGENT CRANIECTOMY: TREPHINING 



Incision. — -The incision will vary with the conditions. We will 
suppose three circumstances: (a) there is an extensive skin wound; 
(b) there is a bullet wound; (c) there is no wound of the soft parts. 

(a) If there is an extensive and ragged skin wound, it is better to 
enlarge it at once by crucial incision. This has the advantage of 
being rapidly done, but has the disadvantage that it interferes with 
the blood supply of the flaps (Fig. 384). 




Fig. 384. — Depressed fracture of the skull. Crucial incision. (Veau.) 



(b) If there is a bullet wound, make a "V '"-shaped flap with the 
bullet wound in the center, and which retains its attachment below, 
the better to conserve the blood supply. 

(c) If there is no open wound, make the same sort of "U "-shaped 
flap with its pedicle downward, over the site of the contusion. 

Cut boldly to the bone if it is resistant. If the fragments are 
mobile under the scalp, proceed cautiously, but do not stop until on 
the pericranium. The incision will often traverse a zone which is 
contused and infiltrated, the various layers being indistinguishable. 

If possible, form the flaps first and then catch the bleeding points 



TREPHINING 



513 



along the edges of the flaps. In some cases it may be necessary to 
clamp a vessel before the incisions are completed. 

As soon as the bone is reached, hurriedly strip back the flaps, in- 
cluding the periosteum. The site of the fracture is now exposed 
(Fig. 385). One of two conditions presents: (1) there are depressed 
fragments which must be removed, or (2) there is & fissure without de- 
pression, but beneath the bone there is a clot to remove and a hemor- 
rhage to check, 

(1) The fragments are often superimposed in two layers and those 
of the internal table are usually the most extensive. In some cases 




Fig. 385. — Stripping back the periosteum to expose the field of fracture. (Veau.) 

the fragments are easily extracted, but in others the bony fragments 
are so wedged in that it is difficult to induce any instrument to pry 
them loose. Failing in this, notch the sound bone along the line of 
fracture with the chisel, and in this manner open up a way to intro- 
duce the elevator. Be careful not to further bruise the brain in 
extracting the fragments, employing only horizontal traction. 
Never wrench or twist the fragments (Fig. 386). 

The deeper fragments are usually adherent to the dura mater and, 
if so, require to be stripped loose before attempting extraction. 

(2) If there exists merely a, fissure, it will be necessary to trephine. 
33 



514 urgent craniectomy: trephining 

At the possible site of the hemorrhage, create an orifice in the skull, 
either with the trephine or with mallet and chisel. 

Trephine. — (A) The ordinary Gait trephine may be employed. 
Begin by protruding its sharp point about 1/16 inch and boring it 
into the skull at the selected site. As soon as the cutting edge of the 
trephine has grooved the skull, retract the point, and proceed to 
deepen the groove by rapid half-rotations of the wrist. From time 
to time, test the groove with the point of a probe to be sure that one 



Fig. 386. — Removal of the fragments. (Veau.) 

side is not cutting faster than the other. If there is any difference, 
regulate the pressure accordingly. Diminished resistance and 
increased blood flow indicate penetration of the outer table. 

The inner table is more resistant, and, when it is reached, one must 
proceed more cautiously. When it is judged that section is com- 
plete, the trephine may be removed and gentle effort made to elevate 
the button. If the bone is completely divided, the button is easily 
removed. 

(B) Doyens' instrument is in less common use, but is simple and 
efficient. It consists of a brace, a perforator, and burrs of various 
sizes (Fig. 387). 

Begin by attaching the perforator and drilling a shallow hole, 



DOYEN TREPHINE 



SIS 



steadying the brace with the left hand. The instrument must always 
be kept perpendicular to the skull. Next replace the perforator with 
a burr and rapidly ream out the opening begun by the perforator. As 
before, one recognizes the approach to the diploe and the inner table. 






Fig. 387. — Doyen trephine. The perforator attached to the brace is used to cut through 
the outer table; the opening subsequently enlarged by burrs of various sizes, replacing the 
perforator on the brace. 

The burr pushes the dura before it without injury (Fig. 388). A 
quadrilateral or circular flap may be outlined by additional openings, 
and the chisel or rongeur used to complete the section of the flap. 

(C) The mallet and chisel may be used and, while not so efficient 
as the trephine, wall serve the purpose. Begin 
by cutting a narrow groove in the skull, deep- 
ening it gradually until the inner table is 
reached and divided. The chief point to be 
emphasized is that the chisel is to be held 
quite obliquely to avoid concussion and un- 
expected penetration. 

Detach the dura mater. Whatever the means 
employed, the dura is now exposed, and if the 
opening, which should have a diameter of at least 2 inches, needs 
to be enlarged, the dura should be detached from the edge of 
bone and the chisel or rongeur employed. Enlarge so as to ex- 
pose as much as possible of the middle meningeal artery. 

Treat the hemorrhage. Once the cranial cavity is well exposed, the 




Fig. 388 — Doyen tre- 
phine; showing manner in 
which the burr approaches 
the dura. 



5x6 



URGENT CRANIECTOMY: TREPHINING 



next concern is the hemorrhage, (a) There is a clot to be removed; 
(b) a bleeding vessel to control. 

(a) The clot may be removed with the finger or with a dull curette. 
The amount of the accumulated blood may be astonishing, but one 
must work patiently. The clot must be removed to the last particle, 
remembering that toward the base there is the greatest abundance. 
The white and resistant dura mater must be exposed in every direc- 
tion (Fig. 389). 

(b) Next look for the bleeding vessel. A jet of blood may indicate 
the proper point at once, and the vessel is caught with forceps and a 




Fig. 389. — Removal of the clot. (Veau.) 



ligature passed with a needle (Fig. 390). If the bleeding point is too 
deep, the forceps may be left in position for twenty-four hours. 
More often, perhaps, the source of the hemorrhage cannot be defi- 
nitely determined and as soon as the compress is removed, the blood 
wells up from the bottom of the cavity. Depressing the head, the 
change in the stream's direction may reveal its source which is liable 
to be the middle meningeal vein; it is to be caught up and ligated 
like the artery. If the blood comes from a sinus, pack the cavity 
with sterile gauze. The hemostasis must be complete. If there is 
only slight, yet persistent oozing, leave a gauze tampon for twenty- 



AFTER TREATMENT 



517 



four hours. Suture the angles of the wound and apply a dry- 
dressing. 

Another case, more rare: The dura mater is lacerated and the brain, 
more or less contused, is exposed. Catch the edges of the dural 
wound with forceps and, raising the membrane, gently wipe out the 
clots with sterile gauze. 

A mere slit in the dura may be repaired by catgut suture, but if 
there is loss of tissue, it is useless to attempt suture of this inelastic 
membrane. The hemorrhage must be cared for in the manner 
already described. 




Fig. 350. — Ligation of the middle meningeal artery. (Veau.) 



Most trying are those cases presenting a subdural hematoma. Tre- 
phining is completed and the dura is exposed, but there is no clot. 
Instead, the dura, tense and darkened, bulges toward the orifice. 
Make a crucial incision in the dura, or raise a flap with its base above, 
and wipe out the exudate, usually diffused. Be very careful not to 
give additional injury to the contused brain tissue. Leave a strip of 
sterile gauze in the wound for drainage, removing it on the second 
day. 

After-treatment. — Following the operation, it may be necessary 
to inject 1 or 2 quarts of salt solution in the first thirty-six 
hours. No alcoholic stimulants must be used. Keep the patient 



518 urgent craniectomy: trephining 

absolutely quiet, the head slightly elevated, and change the dressing 
as often as soiled. If sepsis occurs, open up the wound. If there is 
hernia cerebri, Treves advises a gauze pad saturated with alcohol 
held on under light pressure. 

Results, — -The patient may die without regaining consciousness, 
owing to the shock of the traumatism, aggra ated perhaps by that 
of the operation; for this reason, it is absolutely necessary to give 
as little chloroform and to do the operation as rapidly as possible. 

He may die the next day from persistent hemorrhage. He may 
die between the third and eighth day from septic meningitis, due to 
infection from the injury or the operation. Watch the course of the 
temperature in order to forecast sepsis. 

Finally, he may recover, and even then he may develop a Jack- 
sonian epilepsy, delayed perhaps as long as ten years. 1 

practure op the base of the skull 

It has already been said it would seem that the only way, as cer- 
tainly as may be, to forestall infection in fracture of the base is to 
trephine and drain, leaving a permanent escape for microbes and 
their toxins. If there is evidence of compression originating at the 
base, the trephining is even more imperative. 

Cushing recommends drainage through the lower temporal region 
for the reason that very much more frequently the middle fossa is 
involved, the middle meningeal artery ruptured, and the tip of the 
middle cerebral lobe contused. 

Operation. — Make an incision from the middle of the zygoma di- 
rectly upward to the temporal ridge. Clamp the divided branches of 
the artery. Divide the temporal fascia and split the muscle in the 
same line and cut through to the bone. Strip back the two halves 
of the temporal by free use of the rugine. If there is a line of fracture, 
or some indication of pressure, trephine accordingly. Otherwise, aim 
to make the opening near the junction of the temporal with the great 
wing of the sphenoid. An extradural hemorrhage may be brought 

1 It occasionally happens that the hemorrhage occurs on the side opposite 
the traumatism. There is nothing to do but repeat the trephining on the op- 
posite side, for the matter cannot be determined beforehand. 






TREPHINING THE BASE 519 

to light and a ruptured middle meningeal found. In other cases, the 
effusion will be reached only after the dura is divided. The escape 
of the bloody cerebrospinal fluid will be favored by passing a curved 
blunt dissector down under the temporal lobe. If the effusion is 
merely serous, the wound may be closed; if there is any persistence of 
oozing, a strip of rubber tissue should be left in the lower angle of the 
wound, extending into the cranial cavity under the temporal lobe. 
Vincent (Revue de Chirurgie, Aug., 1909) concludes that this inter- 
vention will reduce materially the sequelae so common to fracture of 
the base not treated by operation. But with this conclusion the 
majority of surgeons do not agree and the tendency is to treat these 
cases by non-operative methods. Certainly for the general prac- 
titioner operative procedures will remain a method only to be em- 
ployed when focal signs of brain pressure are present. 

TREPHINING THE SUBOCCIPITAL REGION 

A case of Ford's illustrates this procedure: A man of fifty years 
fell from a street-car, striking upon his head. He was only slightly 
dazed; insisted he was not hurt and walked home. An hour later, 
his head began to pain severely and in the course of a couple of hours 
he began to grow drowsy and so gradually lapsed into unconscious- 
ness. He developed a divergent strabismus, but his pupils re- 
mained normal and there were no signs of motor paralysis. There 
were no marks about his head to indicate injury. 

After twenty-four hours, Ford was called in. He found the pa- 
tient still unconscious and with the pulse and respiration of com- 
pression. He was removed to the hospital for operation. After the 
head was shaved, a flatness was noticed below the occipital protuber- 
ance, though there was no depression or evidence of contusion. It 
was decided, however, to trephine over this point. A semilunar 
incision, convex upward, mapped out a flap with the base downward, 
and the skull was exposed. A stellated non-depressed fracture was 
found. A trephine button removed revealed the presence of a large 
clot. A large area of bone was removed with rongeur forceps and an 
immense subdural clot cleaned out of the posterior fossa. A strip 
of iodoform gauze was left for drainage. Uninterrupted recovery. 



52 O URGENT CRANIECTOMY! TREPHINING 

We might add that in all cases of head injury followed by compres- 
sion symptoms, but in which there is no evidence of rupture of the 
middle meningeal artery nor any focal symptom, the suboccipital 
operation is preferable to the subtemporal. It will give easier and 
safer access and more efficient drainage. 

TREPHINING THE FRONTAL REGION 

A case reported by Ax tell, of Bellingham, Wash. (Northwest 
Medicine, Nov., 1908), illustrates the procedure: 

A laborer received a violent blow from a cable hook above the left 
eye. In spite of the severity of the injury, the man walked a mile to 
camp. Traveling by a logging train, by boat, and by street car, 
nine hours later he reached the hospital, showing no indication of 
collapse till he reached his destination. He had a marked depres- 
sion over the left orbit, a swollen eyelid, and a protruding eyeball. 

A semicircular incision extending from the bridge of the nose to the 
external angular process exposed the shattered supraorbital ridge. 
The orbital plate of the frontal bone was broken into fragments and 
a large blood clot was found filling the upper and back portion of the 
socket, forcing the eye onto the cheek. 

Three lines of fracture extended from the supra-orbital ridge across 
the frontal, which was depressed in several places. The fragments 
of the orbital plate were removed; and, on removing the depressed 
portions of the frontal, the dura mater and subjacent portion of the 
brain were found mangled. The brain tissue was trimmed out, the 
dura adjusted, and the fragment of the supra-orbital ridge that 
remained attached to the pericranium was so turned and fastened 
that it covered the supra-orbital ridge that had been destroyed. 
This was retained in place by sutures passed through the skin flap 
which was drawn into place. The recovery was uninterrupted, and 
a year after there was nothing to indicate the injury but a puffiness 
of the upper lid. 

Trephining for Gunshot Wounds. — Every case of gunshot wound 
of the skull must be explored; though, of course, no trephining is 
necessary unless there is perforation of the skull or unless there are 
evidences of gunshot fracture without perforation. 



TREPHINING FOR GUNSHOT 52 1 

When it has been determined that there is perforation, raise a flap 
of the scalp with the bullet wound in the center, as has been already 
described. The flap must be larger than the possible trephine open- 
ing in the skull. Enlarge the opening in the skull with trephine, 
chisel and mallet, or with rongeur forceps. Remove all fragments of 
bone and foreign matter, wipe out the dural and cerebral wounds with 
sterile gauze. Be patient and persistent in this cleansing. Do not 
explore the bullet track or attempt to remove the bullet unless, of 
course, it is within easy reach. A case operated by the author illus- 
trates the matter. 

A countryman was shot in the top of the head with a 38 revolver 
by a circus employee, the outcome of a drunken brawl. He was 
carted home to die but after forty-eight hours he was still alive and 
surgical aid was called. He had never regained consciousness and 
he had the pulse and respiration of compression. His kitchen was 
converted into an operating room and the skull trephined. The 
bullet ranged from the center of the vault through the brain to the 
base. Through the ragged hole in the brain the bullet could be felt 
and was removed only to be followed by serious hemorrhage, con- 
trolled by packing with a long strip of iodoform gauze which was 
brought out through the bullet opening in the skin flap in the 
course of repair. 

In an hour after the operation the patient was conscious, his pulse 
and respiration much improved. In a few hours, however, he grew 
restless, and his temperature and pulse rate began to rise and at 
the end of twenty-four hours he was in active delirium. 

The gauze packing was removed followed almost immediately by 
improvement. There was only slight oozing from the wound which 
proceeded to repair without the least sign of infection. 

The man's recovery was rapid and apparently complete, except 
that for some time he had slight disturbance of sight due possibly 
to some traumatism of the visual centers in the occipital lobes. 



CHAPTER V 

MASTOID ABSCESS 

The tympanum, and likewise its accessory cavities, are normally 
sterile, but there are two highways by which infection may reach 
this site; the Eustachian tube, and the external auditory canal. The 
Eustachian canal is the much more common route, the infection first 
gaining a foothold in the mucous membrane of the naso-pharynx, 
so that an inflammation of the mucosa of the middle ear is often only 
a step further in the ordinary pharyngeal catarrhal process. 

Finally, the catarrhal inflammation may become a purulent one, 
in either case, running an acute or chronic course. Again, the pyo- 
genic germ may not long limit its operation to the tympanum; but 
eventually invades the pneumatic spaces adjacent, the antrum and 
mastoid cells; and then there may develop a mastoid abscess, a con- 
dition full of potential danger. The thin roof of the middle ear is the 
dividing line between the posterior and middle cerebral fossae, an 
through it, infection may reach the cerebellum or the middle lob 
of the cerebrum. Meningitis, epidural, cerebral, or cerebellar abscess 
is the immediate result. 

The mastoid cells are separated from the lateral sinus by a bony 
partition, so that through the small venous channels or by necrosis 
of the bony wall, infection may reach the sinus. Finally, general 
infection and sinus thrombosis may ensue, followed perhaps by 
metastatic abscess. 

These are the actual dangers of mastoid abscess and one can never 
tell how fast the pathological process may extend, aided by bone ero- 
sion or by the escape of the infectious matter through apertures in 
the bone or by way of the blood vessels and lymphatics. 

Acute purulent mastoiditis, then, is an emergency, and every doctor 
should feel himself prepared to trephine the mastoid if it beomes his 
duty, and it is his duty if no one more skilled is at hand. 

How shall one recognize this emergency? 

522 



: 



PARACENTESIS 523 

The pain, sleeplessness, prostration, fever, together with the his- 
tory of the case, point with a great degree of probability to the nature 
of the trouble. Now, if the examination adds certain other signs to 
these symptoms, the indications for intervention are definite: 

(1) You find the upper and posterior quadrant of the ear drum 
(Shrapnell's membrane) bulging and perhaps the superior and poste- 
rior walls of the canal are swollen. 

(2) You find persistent tenderness over the mastoid process. 

(3) You may observe that a previously free discharge has suddenly 
diminished and this is an added warning that delay is dangerous. 

To repeat, the cardinal symptoms are pain, redness, swell- 
ing, bulging of the drum, and fever. The first thing to do is a para- 
centesis. 

PARACENTESIS 

Douche the auditory canal gently with warm, sterile water; co- 
cainize the canal with a 10 per cent, solution and wait five or ten 
minutes. With the otoscope, expose the drum and locate the bulging 
area. Puncture it with a small pointed bistoury making an incision 
3 or 4 mm. long, downward and forward. 

There is nothing to fear. Even if the drum has spontaneously 
ruptured, it is often an advantage to enlarge the opening. Usually 
a few drops of pus escape. Follow with irrigation. 

If, at the end of twenty-four hours, the symptoms have not sub- 
sided, proceed without further delay to trephine the mastoid. 

OPERATION FOR MASTOID ABSCESS 

The operation is easy and without much danger if one but knows 
the anatomy (Fig. 395). The sigmoid sinus is more shallow in chil- 
dren than adults. Recall the situation of the spine of Henle, the 
facial nerve, and the lateral sinus. The spine of Henle marks 
the upper limit of the external meatus; 34 i nc h above it is the 
middle cerebral fossa; the mastoid antrum is ^ inch posterior. 

Shave the temporo-parietal region and scrupulously prepare the 
field. General anesthesia is indispensable. 

Special instruments necessary are a Macewen seeker, a chisel (1 



5 2 4 



MASTOID ABSCESS 




Fig 391. — Landmarks of the mastoid. The square represents the area to be trephined; 
•the dotted lines, the course of the lateral sinus. (Veau.) 




Fig. 392. — Incision for mastoid operation. (Veau.) 



TREPHINING THE MASTOID 



525 



cm. wide), a small gouge, mallet, curette, curved periosteal 
elevator, and probe. 

Incision (Fig. 392). — Begin at the apex of the mastoid and follow 
the curve of the external ear to the level of its attachment above. 
This incision reaches to the bone; and, when operating on children, 
be careful not to cut through the bone. Catch the bleeding vessels 
in the gaping wound. Rapidly denude the bone, an undertak- 




Fig. 393. — Denuding the mastoid with the rugine. (Veau.) 



ing somewhat difficult below where the sterno-mastoid is attached 

( Fi g- 393)- 
Introduce a sound into the external auditory canal to determine 

its direction. Expose the spine of Henle. 

Trephine. Start the chisel vertically 5 mm. behind the 

meatus; two or three slight blows of the mallet will be sufficient. 

In a child, a bistoury may be used. Make the second trace with the 

chisel horizontal and on a level with the spine of Henle. The third 

is parallel with the second, and finally the fourth, parallel with the 

first, completes the outline of chip. This fourth line of section is 



526 



MASTOID ABSCESS 



in the danger area, nearly over the lateral sinus. In making it, hold 
the chisel obliquely instead of vertically as in the first (Fig. 394). By 
slight and rapid blows, remove this chip. 




Fig. 394. — Outlining the chip to be removed. (Veau.) 




Fig. 395- — Exposing the lower mastoid cells. (Veau.) 

If this does not expose the cells, deepen the opening carefully with 
the gouge. Pus will often be found at the first incision into the bony 
wall. 



INJURY TO THE LATERAL SINUS 527 

Introduce a seeker or blunt probe, which will locate the various 
cavities and canals leading to the cells of the mastoid and antrum. 
Their coverings are then chipped off, or they may be merely curetted. 

Chisel below first (Fig. 395), and then, with the guide, locate the 
posterior limit of the cells and chisel off the bone lying over the point 
of the guide, A trough may be trephined downward toward the tip. 
Remember that posteriorly there is the lateral sinus (Fig. 396). Do 
not stop until all the cells are freely exposed. 




Fig. 396. — Exposing the posterior cells. The lateral sinus must be avoided. (Veau.) 



When the mastoid cells are thus opened up, it remains to expose 
the antrum (Fig. 397). It lies in the direction upward and forward 
at what seems a considerable depth, 1 to 3 cm. Locate the 
cavity w T ith the guide, and enlarge freely. The mastoid cells and 
the antrum are now a single cavity. Carefully curette the necrosed 
bone and fungosities, but be very careful when curetting over the 
posterior wall, for the lateral sinus may be exposed. Throughout 
the operation, one may be disturbed by the hemorrhage, always con- 
siderable, and it will be necessary to sponge continually, for it is in- 
dispensable that one see what he is doing. 

Certain accidents may occur in the course of the operation. 

(1) The lateral sinus may be wounded, immediately recognized 
by the excessive hemorrhage; but do not be perturbed, for it is easy 



528 



MASTOID ABSCESS 



to arrest the bleeding. Pack the point or apply hot moist applica- 
tions with sterile gauze and continue the operation. If you find 
thrombosis, it will be necessary to open the sinus. 

(2) The cranial cavity may be opened, but neither is this particu- 
larly serious. However, you should avoid, if possible, an injury 
to the meninges, for there is danger of infection. Chisel discreetly, 
therefore, at the upper angle of the opening. 

If you do wound the dura, disinfect and tampon, but do not 
attempt suture. It is scarcely possible at that depth in a cavity so 
narrow. 




Fig. 397- — The operation completed, the guide is in the antrum. (Veau.) 

The facial nerve may get in the way, and if wounded, that is indeed 
a serious matter, for you can do nothing to remedy it. It is deeply 
situated and if you follow the guide, you are scarcely likely to reach it 
with the gouge. It is almost certain to be injured if the mastoid is 
fractured in the course of the trephining, and this will happen if the 
mallet and chisel are recklessly used. Injury to the facial nerve is 
really the one danger of the operation. Close approach is indicated 
by twitching of the facial muscles, and for this the anesthetist should 
be instructed to watch while you are working in the nerve zone. 

Dressing and Subsequent Treatment. — -Partially suture the wound 
and pack with iodoform gauze. The dressings are as important as the 
operation. If neglected, a fistula may form or the suppuration may 



POST-OPERATIVE TREATMENT 529 

recur. Instruct the patient that repair may require six to eight 
weeks, or longer. 

On the second day after the operation, remove the gauze and irri- 
gate with warm sterile water, dry carefully and repack methodically 
so that all the diverticula are filled. They must not be allowed to close 
over. Granulation from the bottom is indispensable. 

Change the dressing every other day. Repress excessive granula- 
tion with tincture of iodine or nitrate of silver. 

Keep the patient in bed for one week; keep the bowels open, and 
regulate the diet. 



34 



CHAPTER VI 

GENERAL TECHNIC OF LAPAROTOMY 

Since so many urgent conditions require a laparotomy, every doc- 
tor should be familiar with the general technic of the procedure with- 
out regard to any particular purpose for which the abdomen may be 
opened. 

For the purpose of ready review, the various difficulties and their 
management and the after-treatment are briefly outlined. 

Preparation of the Patient, — Whenever possible, the patient should 
be under a preliminary treatment for two or three days in order that 
the bowels may be thoroughly cleansed, the field of operation ster- 
ilized with certainty, and the functions of the organs noted. In 
emergency work, these details cannot, of course, be so definitely 
regulated, but to omit any of them is a handicap. 

To have the bowels emptied by castor oil and enemata is the best 
prophylaxis against meteorism, which may be a source of embarrass- 
ment to the operator in the course of the operation, and a source of 
discomfort and perhaps danger to the patient subsequently. 

However urgent the operation may be, the sterilization of the field 
must be definite, even though the methods be abbreviated. To 
scrub with soap and water, shave, wash with alcohol or ether to 
remove the oils, and finally bathe with bichloride solution and cover 
with bichloride compresses until ready to make the incision is to 
realize a practical asepsis so far as the skin is concerned; or the ster- 
ilization may be even more rapidly accomplished by washing, the 
skin with alcohol and ether, shaving and drying; and then painting 
with tincture of iodine. 

To have a definite knowledge of the patient's temperament, of the 
action of his circulation and respiratory organs and of his kidneys 
is to forestall many difficulties and dangers. At least, a full stomach 
should be washed out, and the bladder emptied before the operation is 

530 






TECHNIC OF LAPAROTOMY 53 1 

begun. After the skin is prepared and before the incision is made, 
the field is covered with sterile towels and the whole body with a 
sterile sheet, split over the site of the proposed incision. Small 
towel clamps may be used in fastening the towels to the skin. 

Incision. — -The operator may stand on either side. It is preferable 
to stand to the patient's right and cut from above toward the pubes, 
supposing a median laparotomy. 

The skin and subcutaneous fatty tissues are divided first. Clamp 
the small vessels and gently sponge. In the case of abscess and 
chronic inflammation, the bleeding is likely to be rather free but 
never dangerous. 

The aponeurosis, when possible, should be divided in the linea alba, 
because the bleeding will be less and the access to the peritoneum 
readier. If made on either side of the middle line, the incision opens 
into the sheath of the rectus, whose inner border should be displaced 
to the outer side or its fibers split. The edges of this fascia should be 
caught with forceps in order to be more readily recognized in the 
course of repair. 

The peritoneum is now exposed, covered usually by fatty areolar 
tissue, more or less thick and which may confuse the novice, but it is 
to be cut through without fear until the peritoneum itself appears. 
Catch up a fold of it between two forceps and make a small opening 
with either knife or scissors, using caution not to cut into the bowel 
or omentum. 

The lips of the peritoneal wound are controlled with forceps which 
are to be left attached; and now enlarge the opening in either direc- 
tion, using the finger as a guide and as a protection to the bowel. 
Approaching the pubes, guard against wounding the bladder, of which 
there is no danger if it has been previously emptied. In any event, it 
can be readily located by the sense of touch. 

Protect the Cut Surfaces. — -When the peritoneum is opened to the 
necessary extent, apply two wide compresses of gauze, so as to com- 
pletely cover the incisions and attached forceps, tucking the edge of 
each compress under either side of the peritoneum. This is to 
diminish the chances of infection and to prevent bruising the 
peritoneum. 

In like manner, and for the same purpose, the parts that are to be 



532 GENERAL TECHNIC OF LAPAROTOMY 

dealt with are packed off from adjacent structures with large com- 
presses which are not only more efficient than small ones, but also are 
less likely to be lost within the peritoneal cavity. The surgeon or a 
responsible assistant must always know how many compresses 
are brought into use, and they must be accounted for before the 
cavity is closed. It is remarkable how easily a large compress may 
be lost to sight in the abdominal cavity. It is an added precaution 
to have a tape sewed to each compress, to which a forceps is applied 
after the compress is placed. 

The aim is completely to isolate the part operated on, and once this 
packing is complete the compresses are not to be removed until the 
operation is finished. If infection is present it is well to have two or 
three layers of compresses so that the soiled ones may be removed 
without the bowel being allowed to project into the field. In pelvic 
operations the Trendelenburg position is of great advantage, per- 
mitting the bowel the more readily to be displaced and packed off. 

Management of Peritoneal Adhesions. — The novice and even the 
most practised surgeon may experience the greatest difficulty in sepa- 
rating adherent organs, their peritoneal surfaces glued together as 
the result of inflammation. 

In the case of recent adhesions, they are soft and easily broken. 
In other cases, they consist of bands which need only be divided 
with scissors; but finally they may bind together large areas of adja- 
cent structures so as often to render them indistinguishable. 

Even here with a little patience one may often find a plane of 
cleavage, especially if the parietal peritoneum is involved. If the 
organ cannot be separated from the parietal peritoneum, a segment 
of this latter is to be cut out and left attached to the viscus concerned. 
In the case of the omentum it is to be ligated twice and cut between. 
In the case of the intestine, the greatest care must be used not to 
break through its wall. 

In general, intestinal adhesions discovered in the course of opera- 
tion are not to be broken up except as they interfere with the work in 
hand or are likely to obstruct the bowel. 

If no plane of cleavage can be found, then the other organ involved 
must be deprived of its peritoneal coat to protect the gut. If the sur- 
face of the intestinal loop is left raw after the separation, the Lembert 



DRAINAGE AFTER LAPAROTOMY 533 

suture should be employed. If the bowel wall is torn through, it 
must be repaired by two rows of suture, a through-and-through and 
a Lembert suture. 

Hemorrhage. — The visceral blood supply is complex; to have its 
anatomy clearly in mind is a great advantage in the case of hemor- 
rhage from larger vessels. To locate the vessel at fault, to clamp it 
and ligate quickly, speeds the operation. Capillary oozing can 
generally be controlled by a few moments' application of hot com- 
presses. A compress wet with alcohol will often promptly check free 
bleeding. If the oozing is persistent at the end of the operation and 
measures applied have failed to check it, the abdomen must not be 
closed without drainage. 

To insure against recurrence of hemorrhage as well as to prevent 
infection and adhesions, all raw surfaces should be covered over with 
a peritoneal coat. It is never desirable and seldom necessary to 
leave a denuded area in the peritoneal cavity. Use of the Lembert 
suture and of the free omentum enables one to obliterate them. 
Such as must be left should be sprinkled with aristol. 

Drainage. — The old dictum, "When in doubt, drain," does not 
apply with such force to laparotomy as formerly. In fact, there are 
those bold enough to say, " When in doubt do not drain." Still it 
must be admitted that, in spite of drawbacks, drainage is a real 
safeguard against infection. One should drain, then, when any sep- 
tic process is present or is likely to develop, as in the case of per- 
forating wounds of the intestine. 

Drainage must be employed whenever it is impossible to control 
bleeding from raw surfaces. If there is no infective process present 
in the peritoneal cavity, if there is no obvious reason for any to 
develop later, the abdomen is to be closed completely. 

The preferable method of draining the abdominal cavity is by 
rubber tubes. This is the only method available if pus is present. 
If the main object is to get rid of blood, then the tube should contain 
a wick of gauze which should rest upon the oozing surface that it may 
serve the double purpose of hemostasis and drainage. 

As soon as the oozing has ceased the gauze wick is to be withdrawn 
and usually it is ineffective after twenty-four hours. The removal 
of gauze drains is often difficult and the traction must be gentle. 



534 



GENERAL TECHNIC OF LAPAROTOMY 



The tubal drains are to be removed as soon as the danger of sepsis 
is passed, which is usually after the third day. If at this time 
infection has developed the tube is withdrawn, sterilized, and replaced 
and so on daily thereafter until the suppuration is under control. It 
is in these cases that Balsam Peru is of service in checking the pus 
formation. 

Repair of the Abdominal Wall. — -Suppose the operation complete. 
The final inspection of ligatures and sutures is made, the cavity is 




Fig. 398. — 'Repair of the abdo- 
minal wall. Peritoneum sutured. 
Continuous suture of recti and fas- 
cia begun. (Guibe.) 




Fig. 399. — Fascia repaired. In- 
terrupted skin sutures placed, ready 
to tie. 



wiped out, the compresses are removed and counted, the vessels in 
the abdominal wall that were clamped are ligated, if necessary, and 
repair of the abdominal wall is begun. 

The peritoneum, to which the forceps still remain attached, is 
pulled up into view. If the Trendelenburg position has been used, 
the table is now brought to the horizontal; the intestines are brought 
back into place, the omentum spread out over them, and a compress 
applied to protect the bowel while the peritoneum is repaired with a 



POST-OPERATIVE TREATMENT 535 

continuous No. i catgut suture. The compress is withdrawn before 
the last two or three stitches are passed. 

The aponeurosis and muscles are now repaired with continuous 
chromic gut suture (Fig. 398). 

The skin, finally, is to be repaired with interrupted silkworm-gut 
sutures, passing some of them deep enough to include the muscles and 
aponeurosis so as to obliterate any dead spaces. If coaptation is 
not perfect, a few superficial catgut sutures may be used as necessary. 
One may close the skin simply by the continuous catgut or chromic 
gut suture or, as many prefer, by the subcuticular stitch (Fig. 399). 

Of course, if drainage has been employed, the closure cannot be 
complete, though the suturing is to be carried close up to the tube. 
In case great haste is required, the abdomen may be closed by 
through-and-through sutures of silkworm-gut. 

After-treatment. — In the uncomplicated case, the after-treatment is 
simple. The patient is put to bed with hot-water bottles at his feet 
and provision made for proper ventilation. Fresh air is of the utmost 
importance. As he recovers from the anesthetic, he is given water 
cautiously for the first twenty-four hours. After that, liquid nour- 
ishment should be given in small quantities at frequent intervals. 
The bowels should be moved on the second day by a light soapsuds 
enema. 

It is rare, however, that these patients do not have some complica- 
tion. If there was much shock or much hemorrhage, or if the anes- 
thesia was prolonged, give normal solution by one of the three 
methods, hot coffee by the rectum and whatever cardiac stimulant 
may seem indicated, strychnia, brandy, or camphorated oil. 

If the pain is severe, small doses of morphine hypodermically should 
be given until the patient is comfortable. 

If there is much nausea, try a glass of warm soda-water which will 
probably be thrown up, and thus washes out the stomach. If the 
nausea is quite severe, wash out the stomach and put the patient in a 
half-sitting position. If the thirst is extreme along with vomiting, 
enemas of normal salt solution give the most relief. 

Sometimes 5-15 minims of aromatic spirits of ammonia, given 
hypodermically, tend to relieve the nausea, while acting as a diffusi- 
ble stimulant, 



536 



GENERAL TECHNIC OF LAPAROTOMY 



If there is much flatulence or meteorism, give minute doses of calo- 
mel and empty the bowel with soapsuds enema. If this does not 
give relief, the enema consisting of 2 ounces of Epsom salts and 
glycerin and 1 ounce of turpentine may be employed. 

Acute dilatation of the stomacli must be watched for. If discovered 
at once and properly treated it is not a serious complication. Other- 
wise it may be a large factor in determining a fatality. 

Gastric lavage with alkaline solutions, followed by small doses of 
calomel, usually speedily controls this complication. 

A special line of treatment is required if post-operative ileus develops 
(see page 586). 



CHAPTER VII 
LAPAROTOMY FOR TRAUMATISM 

The indications for laparotomy following traumatism are as follows : 
i. Perforating gunshot wounds. 

2. Perforating stab wounds likely to have wounded a viscus. 

3. Contusions of the abdomen presenting symptoms of dangerous 
lesions of abdominal viscera or vessels; not always definite, but 
operate at once if you find these appearances following contusions: 

(a) The abdominal walls are resistant some distance from the in- 
jury; a progressive meteorism reaching the hepatic region; dullness 
over the iliac fossae or the flanks, indicating hemorrhage. 

(b) The pulse is weak and rapid, and growing worse. 

(c) The general condition of the patient is alarming, pallor, pain, 
excitement or delirium, subnormal temperature. 

But whether it be an open wound or a contusion, do not wait for 
the symptoms of peritonitis, for it will then likely be too late. The 
operation is delicate and dangerous in the hands of the unskilled, 
and yet the patient's life depends upon it. There is no time to send 
for a specialist unless he is right at hand, and, as Veau says, it is 
better for the patient to be operated on early by an inexperienced 
surgeon than to be operated on too late by the best surgeon in the 
land. It is an intervention in which one never knows what he is 
going to find. 

The steps of the operation are: 

(1) A laparotomy. 

(2) Search for the hemorrhage if there is blood in the abdomen. 

(3) Search for visceral injuries. 

General anesthesia is indispensable, and ether is preferable unless 
compelled to operate in close quarters by lamp light. Every pre- 
caution must be taken not to aggravate shock; the limbs should be 
wrapped and the chest protected. The whole anterior abdominal 

537 



538 



LAPAROTOMY FOR TRAUMATISM 



wall must be sterilized. Be prepared for normal salt injections, 
often necessary throughout the operation. 

(i) Laparotomy. Whatever be the site of the wound or contusion, 
make an incision in the middle line; below the umbilicus, usually; 
above, if the injury points to the epigastrium. The incision at first 
should be about 3 inches long. It will be necessary to extend 
it if the preliminary examination reveals visceral injuries. Divide 
the skin and fatty tissues and catch up the bleeding vessels. Look 

for the linea alba, but if not readily 
found, go through the muscle; it does 
not greatly matter. Divide the 
transversalis fascia and expose the 
subperitoneal fatty tissue. It may 
be quite thick. 

The peritoneum will probably not 
be recognized by its appearance, but 
rather by observing the tissues gone 
through. It is usually bulging. 
One may be able to see free blood 
in the cavity by reason of its trans- 
parency. 

Catch up the peritoneum with 
dissecting forceps and incise the cone 
thus formed, with the cutting-edge 
of the scalpel turned away from the abdominal cavity, that the 
bowel may not be wounded (Fig. 400). Enlarge the small open- 
ing thus created, and direct the assistant to seize the lips of the 
peritoneal wound with forceps. 

Pay no attention to the blood which may pour out, but proceed 
rapidly to elongate the peritoneal wound with the scissors, protect- 
ing the bowel with the left index finger (Fig. 401). Remember the 
peritoneum envelops the bladder, so do not open the peritoneum 
down to the pubes, although the skin wound should be carried thus 
far in order to give the best view (Fig. 402). 

Carefully catch up the lips of the peritoneal wound with forceps 
which may also serve as retractors; such control of the peritoneum 
will also facilitate its suturing at the end of the operation. It may 




Fig. 400. — Incising the fold of 
peritoneum. (Guibe.) 






SOURCES OF HEMORRHAGE 



539 



now be necessary to push the anesthesia a little if there is much 
resistance, 

(2) Locate and check the hemorrhage. Do not be in a hurry to 
put a hand in the cavity but observe closely, sponging gently. The 
character of the fluids may be helpful in diagnosis. The examining 




Fig. 401. — Enlarging the peritoneal opening with the scissors on the index finger 

to guide. (Guibe.) 



finger may detect lesions, or the injured viscera may push up into 
the wound. 

The hemorrhage may come from the following: (a) omentum; 
(b) mesentery; (c) the vascular organs, liver, spleen, kidney; (d) 
the vessels of the posterior abdominal wall. 

(a) The great omentum should be gently lifted out of the cavity. 



54° 



LAPAROTOMY FOR TRAUMATISM 



It may contain a hematoma and the divided vessels be hard to find. 
Tie them with No. 2 catgut. If the omentum is torn and lacerated, 
resect the injured portion (Fig. 410). It may be split; the large 
vessels opened -must be tied; the small will be controlled by the con- 
tinuous suture, which should reunite the edges of the wound. If the 




Fig. 402. — Enlarging the opening toward the pubes, the bladder must not be 

wounded. (Guibe.) 

omentum is detached from the greater curvature, the stomach should 
be exposed, and the omentum sutured thereto. 

(b) The hemorrhage from the mesentery may be arrested in the 
same manner, though one may not find it until in the course of in- 
specting the gut. Mesenteric wounds often exist without visceral 
injury. In suturing the tear, the needle must be passed close to the 



WOUNDS OF THE BOWEL 54 1 

edges of the wound so that no vessel may be wounded or included in 
the tie. 

If its attachment to the bowel is disturbed for, say, more than 3 
inches or if it is necessary to tie a branch as large as the radial, the 
integrity of the corresponding section of gut is compromised and it 
will be advisable to resect. If unable to do that, treat it as the 
doubtful bowel is treated in strangulated hernia (see page 609). 

(c) If the hemorrhage proceeds from a wound of the liver, spleen, 
or kidney, tampon methodically and firmly with sterile gauze. 

If the liver is ruptured extensively and tamponade has no effect, 
try deep suturing. If this does not succeed, the wound is probably 
beyond surgical aid. 

If the spleen is extensively lacerated, remove it (see page 549). 

(d) If the vessels of the posterior abdominal wall are involved or 
the splenic, mesenteric, or renal, it will often be very difficult to 
find the starting-point^of the hemorrhage, for it is in the midst of a 
great clot. Begin by applying a large compress to the suspected 
point and make firm pressure. Following this, rapidly wipe out 
all the clots and reapply the compress. Raise its edge gradually 
and as each bleeding point appears, clamp it. It will often be im- 
possible to ligate at that depth and forceps are left attached. The 
forceps are to remain twenty-four to thirty-six hours. These must 
be removed without violence. 

(3) Wounds of the Intestine: Do not forget that intestinal per- 
forations are often multiple, are usually so after gunshot wounds, so 
that it is absolutely necessary to inspect the whole intestine that no 
wound may be overlooked. 

(A) Examination of the Bowel. — The procedure must be methodical. 
Do not pick up first one segment and then another indiscriminately; 
in this way one part may be examined several times and another part 
not at all. 

Begin by picking up with forceps any part of the bowel that may 
present; these forceps will serve as a starting-point and landmark. 
It will not hurt the bowel with its pressure, as it includes in its hold 
only the serous and muscular coats (Fig. 403). 

Begin at this point, then, pulling up to view segment after seg- 
ment, and as it is inspected, return it to the cavity. The ma- 



542 



LAPAROTOMY FOR TRAUMATISM 



neuver may be attended with difficulty especially if one is compelled 
to operate late, when peritonitis has begun and the partially paralyzed 
bowel is greatly distended. If several folds of the bowel should 
escape and there is difficulty in returning them, the procedure as 
described on page 131 will be helpful. 




Fig. 403. — Examining the bowel. (Veau.) 

Begin by lifting up the abdominal wall by means of the retractors. 
Cover the refractory mass with a wide compress and then tuck each 
border of the compress into the wound, gradually working it into the 
abdominal cavity. It will carry the bowel along. Then carefully 
withdraw the compress. 

Examining thus the small intestine, one of its fixed points will 
finally be reached, either the cecum or the duodenum; return then 
to the forceps and work in the other direction. 1 

1 In the case of gunshot wounds penetrating the abdomen from behind, the 
difficulties in locating the injuries may be greatly increased, a fact illustrated by 
the following case: 

A colored man was brought to the City Hospital with a gunshot wound in the 
back, the bullet entering the right lumbar region about 2 inches from the 
middle line. Progressive abdominal distention and tenderness with symptoms 
of hemorrhage pointed to a visceral injury. He was immediately operated upon; 
the abdomen was opened below the umbilicus. The pelvis contained consider- 
able blood, but there was not the quantity expected. A systematic examination 
of the intestine from the cecum to the duodenojejunal juncture revealed no per- 



REPAIR OF THE INTESTINE 



543 



Whenever a perforation is found, it must be repaired before look- 
ing further. 

(B) Repair of the Intestinal Wound. — -When an intestinal wound 
is located, seize its edges with two forceps, including only the serous 
and muscular coats, draw the part outside the cavity and isolate it 
with compresses and then suture. 

(a) Non-perforating wounds are sufficiently repaired by two or 
three Lembert sutures. 

(b) Small perforating wounds, such as bullet wounds, must be 




Fig. 404. — The inclusive suture passed; tied and Lembert suture passed; Lembert tied. 

repaired by suture in two layers (Fig. 404). With fine silk, No 1, 
make a suture which includes all three coats, serous, muscular and 
mucous (Fig. 405). If the wound is longer than two- thirds of an 
inch use two such sutures, etc. These sutures are to be covered in 
and buried by the second layer, which involves only the serous coat 
(Lembert suture). In introducing them, begin at least % inch 

foration. No opening in the posterior abdominal wall could be found below the 
level of the umbilicus. The incision was extended and the examining finger 
located a tear behind the stomach. At this time the patient's condition grew so 
bad it was necessary to cease the search and before the abdomen could be com- 
pletely closed, he died. 

The post-mortem revealed a long tear in the transverse portion of the duodenum. 
The bullet had struck the transverse process of a lumbar vertebra, had deflected 
to the left, wounding the ascending vena cava and the duodenum, and had lodged 
in the anterior abdominal wall. The blood escaping from the vena cava had not 
emptied into the abdomen, but had followed the vein along the spine and had 
flooded the posterior mediastinum. 



544 



LAPAROTOMY FOR TRAUMATISM 



back of the first line and use either a continuous or interrupted suture 
(Fig. 406). 

(c) Large Perforating Wounds. — If the wound is an incised one. 





Fig. 466. — The first layer of sutures 
include all coats. (Veau.) 



Fig. 407 — Applying sero-serous 
(Lembert) sutures. (Veau.) 



suture without refreshing the edges, but if it is contused or lacerated 
(Fig. 408) it will be necessary for repair to trim away to the sound 
tissue; but take care not to diminish the caliber of the gut. 




Fig. 408. — Trimming away the 
bruised tissue. (Veau.) 




AM 



Fig. 409. — Transverse suture to prevent 
narrowing of the bowel. (Veau.) 



As before, beginning at one angle, introduce the first line of the 
suture, including all the coats, and using, if possible, a continuous 
suture (Fig. 409). 




POST-OPERATIVE TREATMENT 545 

The second line of (Lembert or sero-serous) sutures must begin 
and end % inch beyond the limits of the first and the needle must 
be entered far enough away from the first line that the peritoneal 
surfaces may be well apposed and the first layer completely covered 
(Fig. 410). 

(C) Resection of the Gut. — If the wound involves more than two- 
thirds of the circumference or if there is a contusion of the whole or 
a large part of the segment, it will be necessary to resect and do a 
circular enterorrhaphy or some other form of 
anastomosis. If the operator cannot undertake 
that, then the gut must be treated as in the 
gangrene of strangulated hernia, making an 
artificial anus (see page 651). For resection of 
gut, see page 609. 

Drain the peritoneal cavity with a Miculicz 
drain where there is oozing, and with a drain- 
age-tube if infection is feared (see Chapter V on "•£* 

Drainage) . FlG - 4io.— Applying Lem- 

Close the abdominal wall by three tiers of 
suture; the peritoneum with a continuous suture of catgut, the 
muscles with chromicized catgut, and the skin with silkworm-gut. 
Apply a dry dressing. 

Subsequent Care. — Order complete rest and absence of food for 
forty-eight hours, not even excepting milk. To quench the thirst, 
let the patient suck a cloth saturated with water. It will nearly 
always be expedient to give salt solution either by rectum or sub- 
cutaneously; in the worst cases by intravenous infusion. 

Change the dressing the following day. It will probably be satu- 
rated with bloody serum. On the second day remove the tampons 
and replace with smaller ones. On the fourth day remove the drain- 
age-tube, if employed, and replace with smaller one, which may be 
dispensed with after the eighth day. 

Prognosis. — The prognosis will depend upon the extent of the 
injuries and the skill of the operator. 

Death may occur from hemorrhage or peritonitis shortly after the 
operation, or about the eighth or tenth day if the suturing has been 
imperfectly done. 
35 



546 LAPAROTOMY FOR TRAUMATISM 

Fecal abscess and fecal fistula may result, requiring a later opera- 
tion, or which may eventually cure themselves. 

Complete recovery happily very often occurs and would be the rule 
if the doctor had the judgment or authority to operate within the 
first few hours after the traumatism. 

WOUNDS OF THE STOMACH 

If the injury involves the upper pole of the abdomen, the stomach 
must be examined carefully. Extensive injuries are often overlooked. 
An escape of gas and bleeding may point to the situation of the lesion. 

Pick up the stomach with gauze to get a firmer hold, and examine 
the anterior surface systematically. Repair any wounds, as in the 
intestine, by two rows of suture; the one including all the coats, the 
other only the serous and muscular. 

In the case of gunshot wounds, examine the posterior surface. To 
reach the posterior surface, Auvray insists upon a large incision in 
the gastro-colic omentum along the lower border of the stomach, 
for a large incision facilitates examination and does not compromise 
the vitality of any structure. If even then one cannot gain full 
access, he advises an exploratory gastrotomy (Revue de Chirurgie, 
Nov. 10, 1906). 

The posterior surface may be reached another way, by turning 
up the transverse colon and opening the transverse meso-colon. To 
prevent the spread of fluids which may escape from the stomach 
the field must be carefully walled off with compresses as the explora- 
tion proceeds. If the wound can be felt but is impossible to be seen, 
then no attempt must be made to suture, but the cavity is to be 
thoroughly drained. 

If there has been much loss of substance, it may be necessary to do 
a gastro-enterostomy. 

WOUNDS OF THE LIVER 

If the nature of the abdominal injury leaves no doubt that the 
liver is wounded, it may be advisable to vary the procedure as al- 
ready described. A support under the back tilts the abdomen so 
that the intestine drops down toward the pelvic cavity, and at the 
same time the liver is bulged forward and made more accessible. 



REPAIR OF THE LIVER 



547 



The incision beginning at the ensiform cartilage may follow the 
costal arch, dividing, if necessary, the right rectus muscle. It may 
even be necessary, in order to reach the upper surface of the liver, 
to resect the tenth, ninth, or eighth rib. 

You mav find on examination of the viscera that the liver has been 




Fig. 411. — Suture of the liver. (Moynihan.) 



contused, and there is evidently a hematoma formed beneath the cap- 
sule. It is better not to disturb it unless the conditions seem to 
indicate continuation of oozing. 

There may be an open wound of any character or extent with great 
hemorrhage. One should attempt to catch up and ligate the bleeding 
points, employing a fine clip or artery forceps. The veins, as well 
as the arteries, will stand the strain of a ligature, but may need to be 



548 LAPAROTOMY FOR TRAUMATISM 

dissected loose from the liver substance before the ligature can be 
applied. 

If the patient is not too weak, attempt repair by suture. It is a 
little difficult, but quite possible and certainly desirable. 

Employ a blunt-pointed needle and do not push it through boldly, 
but slowly, and as you push, gently oscillate the needle. In this 
manner, the point may slip by the vessels. Employ a large catgut 
suture, as a fine suture cuts through the soft tissue (Fig. 411). 

Van Buren Knott (Iowa Med. Journal, Oct., 1907) recommends 
inserting a strand of catgut parallel with the liver wound, tying the 
ends of the strand over small skeins of catgut to prevent tearing 
Transverse interrupted sutures are then passed so as to include the 
parallel sutures first passed. 

Failing to suture, there is nothing left but the tamponade, and this, 
of course, is the only thing available in lacerated wounds. 

Haynes, of New York (Annals of Surgery, July, 1907), describes 
a case illustrative of some of the difficulties of treatment and the 
sequelae of liver wounds. 

Patient, a man of twenty years, was brought to the Harlem Hos- 
pital with gunshot wound just below the tip of the ensif orm cartilage. 
The bullet was found to have traversed the liver from before back- 
ward, and it was necessary to get at the wound of exit. 

From the median incision, a second incision was made transversely, 
dividing the right rectus and the seventh and sixth costal cartilages. 
The falciform ligament was also divided. With strong traction upon 
the costal arch, the posterior wound could be reached and felt but 
not seen, readily admitting two fingers. 

By the sense of touch, an iodoform wick was packed into this 
wound and a smaller one introduced into the anterior wound, and 
both brought out through the abdominal incision. This did not 
entirely control the hemorrhage, and so the liver was forced up 
against the diaphragm and held by a large Miculicz tampon below 
the liver. 

The rectus was sutured. The peritoneum was repaired with the 
falciform ligament included; the abdominal walls sutured above and 
below the gauze wicks. 

On the tenth day the tamponade was removed; and a few days 



REPAIR OF THE PANCREAS 549 

later, the gauze wicks, for which rubber tubes were substituted, a 
discharge of bile and pus being present. 

At the end of the third week it became necessary to secure addi- 
tional drainage, and the ninth rib was resected in the axillary line, 
where, in the meantime, the bullet had been located; the costal and 
phrenic pleura were sutured, and the pleural cavity thus shut off. 
The diaphragm was opened, the pus drained out and a long tube 
passed from the anterior to the posterior abdominal wounds, and a 
smaller one left in the posterior wound. 

The progress of repair was slow but sure, five months elapsing 
before the cure was complete. 

It should be remarked that very rarely after gunshot wounds of 
the liver is there notable external hemorrhage. One must determine 
the degree of injury from the signs of internal hemorrhage and the 
evidences of peritoneal reaction which later develop. 

WOUNDS OF THE PANCREAS 

Do not forget to examine the pancreas in wounds of the upper 
zone of the abdomen. Reach the pancreas from above the stomach, 
opening through the gastro-hepatic omentum. 

Carefully mop out the fluids, blood and pancreatic juice. Pack 
around the site with compresses and try to suture. Sometimes two 
or three deep sutures will coapt the wound surface and completely 
check the hemorrhage. If the tail is much crushed, resect it and 
suture the stump. Use gauze and tubal drainage. If the patient 
does not die, he may have a subphrenic abscess (Figs. 412, 413). 

WOUNDS OF THE SPLEEN 

Any but the slightest wound of the spleen is universally and rapidly 
fatal from hemorrhage unless treated. One naturally thinks of 
suturing. If that and tamponade are not effective to stop the 
bleeding, it is indicated to try to remove the viscus. This is not 
difficult if there are no adhesions, though, if there are, failure is 
almost certain. Under such circumstances, as Moynihan suggests, 
the only thing left is to pack with gauze, soaked, if necessary, in 
adrenalin solution. 



55o 



LAPAROTOMY FOR TRAUMATISM 



Noetzel reviews his experience with six cases in which he removed 
the spleen for injury and concludes that splenectomy is the only 
safe way of securing hemostasis. Suturing and tamponing may 
arrest bleeding for a time, but there is danger that it will return. 

Holliday, of Portsmouth, Virginia, reports a case illustrating the 
subject (Virginia Medical Semi-monthly Journal, January n, 1907); 
patient, boy, age 15, was struck in left side by a flying pulley, frac- 
turing his arm in several places and contusing the abdominal wall. 
His condition shortly became serious; temperature subnormal, 
absolute dullness on the left side, and marked rigidity. Immediate 




Figs. 412 and 413. — Method of suture of a wound in the pancreas. Two or three deep 
sutures of stout catgut or silk are passed, and wound-surfaces drawn together. The wound- 
edges are then sutured with fine catgut sutures. (Moynihan.) 



operation. The patient was almost eviscerated before the bleeding 
could be located, but which was finally found to proceed from the 
lacerated external surface of the spleen; a splenectomy was quickly 
done, and the abdomen closed without drainage. Convalescence 
was easy and uneventful. 

Splenectomy. — The operation following rupture generally finds 
the incision made in the middle line on account of the indications 
for hemorrhage. 

The spleen is brought up into view and delivered from the abdom- 
inal cavity and clamped, avoiding any strain upon its pedicle, for the 
veins have extremely thin walls (Fig. 414). 

Ligate and divide the pedicle. Transfix the pedicle with a double 
ligature and tie each half separately, and finally tie the whole pedicle 
in a single ligature. If the ligament is large and thick it may be 



SPLENECTOMY 551 

necessary to ligate it "enchaine" (Fig. 415). The pedicle is next 
divided, the spleen removed, and its bed examined for any bleeding 
points, The under surface of the diaphragm is very likely to present 
some oozing. 

Fiske, of Brooklyn, describes a case which illustrates the varia- 
tions in the procedure. (Annals of Surgery, Jan., 1908.) 

A man of twenty-five years was brought to the Kings County 
Hospital with a bullet wound in the left side corresponding to the 




Fig. 414. — Splenectomy: Clamps applied to pedicle preliminary to section along dotted 

line. (Guibe.) 



spleen. The symptoms pointed to visceral injury and intra-abdom- 
inal hemorrhage. An incision was made over the outer border of the 
left rectus muscle from the costal arch to a point midway between the 
umbilicus and symphysis. The stomach and intestine were found to 
be uninjured. A perforation in the transverse meso-colon was re- 
paired, but the hemorrhage continued. A transverse incision was 
made and the spleen examined, revealing a rent which admitted two 
fingers. The spleen was pulled up into the wound, the pedicle 



552 



LAPAROTOMY FOR TRAUMATISM 



clamped and ligated en masse. After removing the spleen, the ves- 
sels were ligated separately, the abdomen was flushed with saline 
solution, a small gauze drain left in contact with the stump, and the 
wound closed with through-and-through silkworm-gut sutures. 
The temperature subsequently did not rise above ioo°. The drain 
was permanently removed on the fifth day. The patient left the 
hospital at the end of the third week, entirely recovered. 




Fig. 415. — Pedicle of spleen ligated "enchaine". (Guibe.) 



WOUNDS OF THE KIDNEY 

If, while examining the viscera in the course of the laparotomy, 
you find a ruptured renal pelvis or a seriously lacerated kidney bleed- 
ing into the peritoneal cavity, remove the kidney. Make a longitu- 
dinal incision in its peritoneal covering, strip the organ out of its bed 
and, lifting toward the surface, free the pedicle. 



REPAIR OF THE KIDNEY 553 

Ligate the ureter first and then, if possible, each of the vessels 
separately. If the oozing persists, leave a Miculicz drain or a rubber 
tube. 

Intra-peritoneal rupture without injury to other viscera is very 
rare. 

Extra-peritoneal wounds of the kidney do not, as a rule, require 
intervention. 

That the kidney has been involved will be suggested by pain, 
frequent micturition, and bloody urine. 

Rest in bsd, morphine, and limited diet are the special indica- 
tions. An abdominal binder may give relief. 

Eliot (American Journal Surgery, Nov., 1906) has observed twelve 
cases of subcutaneous rupture of the kidney. In seven cases there 
was not sufficient extravasation to make a perceptible tumor, and the 
diagnosis was made by the hematuria and the tenderness over the 
kidney and persistent rigidity for a number of days. 

In the remaining cases a well-defined tumor appeared in the ilio- 
costal space, becoming more sharply outlined as the rigidity dis- 
appeared. In five or six weeks, the tumorjiisappeared. In no 
instance was operation necessary. 

In such cases of extra-peritoneal rupture as require operation, the 
lumbar route should be chosen. Operation is indicated from the first 
if the violence was known to be great and a large tumor forms im- 
mediately. An operation is indicated at any time symptoms of sepsis 
appear, 

Morris Miller reports a case (Annals of Surgery, Feb., 1908) of a 
man who fell, striking his left side over the lower rib. He felt faint, 
and almost immediately passed a quart of blood by the urethra and 
later may clots. Miller saw him at the hospital an hour and a half 
later. There was no shock, but the side was rigid and tender, and an 
indistinct dull mass could be felt in the loin. An oblique lumbar 
incision revealed an extensive rupture of the kidney with much 
hemorrhage. Wicks of gauze were placed in front and behind the 
kidney and the ruptured segments pressed together. The patient 
did well, the hemorrhage gradually ceased, though twice after the 
fifth day blood appeared in the urine. On the twelfth day the pack- 
ing was all removed, and the opening finally healed. Gibbon, com- 



554 



LAPAROTOMY FOR TRAUMATISM! 



meriting on the case, remarks that hemorrhage severe enough to 
require operation does not usually mean injury sufficient to require 
nephrectomy. The question of nephrectomy must be decided when 
the kidney is exposed. 

Stewart adds that the two early indications for operation are a 
progressively increasing hematoma and constitutional symptoms of 
hemorrhage. In several cases of moderate bleeding he had operated, 
and afterward been sorry he had interfered. 




Fig. 416. — Repair of ruptured bladder. Applying through-and-through sutures. Sub- 
sequently Lembert suture will be applied and finally the parietal peritoneum will be repaired 
beginning at point of reflection onto the bladder. Peritoneum retained by forceps. (Lejars.) 



WOUNDS OF THE BLADDER 

Wounds of the bladder, if not previously suspected from the nature 
of the abdominal injuries, are inferred from the presence of urine in 
the peritoneal cavity. Sometimes the rent is hard to locate. Inject 



REPAIR OF THE BLADDER 



555 



the bladder with normal salt solution and observe its mode of en- 
trance into the peritoneal cavity. 

The wound is to be repaired by two rows of sutures, the first, of 
catgut, involving all the coats except the mucosa; the second, of 
silk, includes the peritoneum alone after the manner of the Lembert 
suture. The stitches of both rows must be closely placed to seal the 
wound. The result may be tested by filling the bladder with normal 
salt solution, and any defect repaired (Fig. 419). 






Fig. 417. — Van 
Hook's ureteral an- 
astomosis. (Binnie.) 



Fig. 418. — Van Hook's 
ureteral anastomosis. 
(Binnie.) 



Fig. 419. — Anasto- 
mosis completed. 
(Binnie.) 



A catheter should be left in the bladder for drainage and the 
' siphonage kept up for two or three days. Subsequently, the bladder 
should be emptied by aseptic catheterization for a few days longer. 
The peritoneum should be drained for the first forty-eight hours. 

This mode of treatment applies to the intra-peritoneal wounds of 
the bladder. The extra-peritoneal wounds should be treated on the 
same principle, but often, under such circumstances, the operator 
must be content with suprapubic drainage of the bladder until the 
wound has healed. 



556 LAPAROTOMY FOR TRAUMATISM 

WOUNDS OF THE URETER 

If it is discovered that the ureter is wounded either by the trauma 
or in the course of the operation, an effort should be made at repair. 
Several methods are available. If the injury does not amount to 
complete division, a few perforating sutures followed by Lembert 
sutures may succeed. Small wounds usually heal readily, but it is 
safer to use drainage. 

If the separation is complete, both ends of the torn ureter may be 
ligated, or the kidney may be removed, but naturally it is preferable, 
if possible, to establish an anastomosis. Under various circum- 
stances, the proximal end may be anchored in the bladder or in the 
bowel, or the two ends may be brought together. 

Van Hook's termino-lateral anastomosis is generally applied. 
The technic may be briefly described in this wise: 

Ligate the distal portion 1/4 inch from the end and make a longi- 
tudinal slit in length double the diameter of the tube. Split the 
proximal end also for 1/4 inch, beginning at the free end. 

Pass the sutures. Employ a long catgut suture threaded on a 
needle at each end. One-eighth inch from the end of the proximal 
portion of the ureter, pass the two needles from without inward 
(Fig. 417). Carry the two needles through the split in the distal 
portion, into the lumen and let them emerge 1/2 inch below 
the end of the split (Fig. 418). Tighten the suture, which will have 
the effect of invaginating the upper segment in the lower (Fig. 419). 
Around the line of contact run a Lembert suture, and cover with 
omentum or peritoneum. 



CHAPTER VIII 

APPENDICITIS. APPENDICIAL ABSCESS. PURULENT 

PERITONITIS 1 

Inflammation of the appendix presupposes two factors, lowered 
resistance and a pathogenic germ. 

The lowered resistance of the appendicial tissue may find its 

origin in many diverse conditions involving its morphology, anatomy , 

and physiology. It is generally agreed that it is an organ undergoing 

a retrograde metamorphosis, or, at any rate, one adapting itself to 

c new functions. 

There is a small facility for compensatory circulation if its main 
artery is blocked, and, in consequence, it is exposed to vicissitudes of 
I nutrition. 

Owing to its varying position, it is brought into contact and may 

acquire connections, vascular and lymphatic, with other abdominal 

and pelvic organs and structures and, by this means, be the recipient 

J of pathogenic bacteria that had not elsewhere found a favorable soil. 

The pathogenic organisms which, under favorable conditions, may 
here develop and produce various grades of destruction are the bacil- 
lus communis coli, the streptococci, staphylococci, and others less 
1 frequent. 

Whatever part each of these causative agents may play in its de- 
velopment, the fact remains that appendicitis is one of the frequent 
and one of the most dangerous and treacherous diseases with which 
the general practitioner has to deal. 

Diagnosis. — The diagnosis is not difficult in the typical cases, 
but exceptionally may be extremely difficult, or even impossible, 
until the progress of the symptoms has been observed. 

A diagnosis should never be made from the mere presence of what 

1 So important is this subject to the general practitioner, that he should be 
satisfied to have and study no works less complete than the classic volumes of 
Deaver or Kelly. 

557 



558 APPENDICITIS. PURULENT PERITONITIS 

are regarded as the cardinal symptoms; not until each symptom and 
sign has been weighed and accorded its proper significance, and all 
other possible conditions excluded, should it be decided definitely 
that the case is or is not acute appendicitis. 

To discuss briefly the symptoms upon which one must rely: the 
pain in the milder catarrhal cases is limited usually to the right iliac 
fossa. In the ulcerative type, with sudden onset, or the perforative 
type, it is very likely at first to be general over the abdomen, but after 
a few hours, is rather definitely localized in the right side. In the 
gangrenous cases, it may be absent in one case or severe in another, 
depending upon the degree of active peritoneal inflammation. 

Rigidity of the right rectus abdominis and pelvic muscles is an 
important sign, and its degree is some index to the amount of perit- 
oneal involvement. 

Gastric disturbance, nausea, and vomiting are fairly constant oc- 
currences in the first stages of the attack, but last only a short time. 
T. B. Eastman has very strongly emphasized the frequent connec- 
tion between the chronic forms of appendicitis and those appearances 
of gastric indigestion vaguely grouped as " stomach troubles. " 

Constipation is almost the rule, and Kelly adds further that it may 
amount to an actual obstruction. Only rarely does diarrhea appear 
with the attack, and if it does, may be regarded as indicating a grave 
form. Most rare of all is it for an attack even of the mildest type, 
to run its course without some aberration of bowel action. 

Tenderness on pressure is a symptom upon which alone the diag- 
nosis is too often made. It is scarcely possible for it to be wholly 
absent, and yet it can by no means be relied upon to indicate the 
severity of the attack. Rosving states that pressure < on the left 
McBurney point always elicits pain in appendicitis, but not in other 
cases. 

Robert Morris adds something to this phase of the diagnosis. He 
claims that tenderness upon pressure over a point opposite the um- 
bilicus in the line of the anterior superior spine of the ilium has a 
special significance and is due to involvement of the lumbar ganglia. 
Thus Morris' point on the right side will be tender in appendicitis. 
If that point on both sides is tender, the trouble is located in the 
pelvis. 



DIAGNOSIS OF APPENDICITIS 559 

[ Tumor. — It is folly to wait for this sign to complete the diagnosis, 
for it means the certainty of a complicated pathology. It means 
peritoneal involvement with plastic exudates, or a pus formation, or 
both. 

Disturbance of Pulse and Temperature. — There is no other grave 

disease, perhaps, in which the pulse and temperature make such 

3 limited excursions. The temperature in the most serious cases may 

j not reach 103 . Its elevation is in no wise significant. The pulse 

: in the milder cases holds a certain ratio with the temperature. A 

temperature of 101 , for example, should be accompanied by a pulse 

rate of 90 to 100. Any marked disturbance of this ratio is extremely 

significant; whether it is a low temperature with a rapid pulse or a 

. high temperature with a slow pulse, the outlook is ominous. H. O. 

Panzter, from extended clinical experience, insists that we must rely 

largely upon the rectal temperature in making a differential diagnosis, 

and that the temperature should be invariably taken by both mouth 

and rectum. The temperature by mouth in such cases may be very 

; deceptive. 

Such, very briefly, are the principal symptoms and signs which, 
taken collectively, must serve to distinguish the disorder from acute 
intestinal obstruction, ovarian or tubal inflammation, cholecystitis, 
typhoid fever, pneumonia, and other acute diseases. 

There is not much danger at the present time, so prominently is the 

subject before the profession, that an appendicitis will be overlooked. 

Only too often is an innocent appendix held to be the cause of the 

, illness in hand, Lobar pneumonia, for example, is likely to give rise 

i to appendicial symptoms, and such cases are likely to run an atypical 

course. 

It is an appendicitis, but what is its character? Is it mild or 

dangerous? Is it a simple catarrhal trouble which will soon subside, 

or is it potentially a gangrenous process with general peritonitis 

ahead? These are the questions which confound the doctor and 

I upon their answer rest the prognosis and treatment. 

Four varieties are described (Fig. 420). 

(1) Catarrhal appendicitis, in which the mucosa alone is involved, 
the predisposing causes are easily relieved, and the pathogenic agent 



S6o 



APPENDICITIS. PURULENT PERITONITIS 




*> 







cvj I 





l^ L ... 



Pig. 420. — Types of appendicitis showing pathological changes. 1, Normal appendix 
2, acute appendicitis; 3, inflamed appendix containing large and small fecolith; 4 
Ruptured gangrenous appendix containing large fecolith. (Reed and Carnrick.) 



DIAGNOSIS OF APPENDICITIS 56 1 

is of a low order of virility. Neither local nor constitutional symp- 
toms are severe, and the attack very shortly subsides. 

(2) In the ulcerative type the process extends deeper and involves 
the muscular and perhaps the serous coat to some extent and there 
is produced a mild form of peritoneal inflammation. There is usu- 
ally a diffused swelling of the w T hole appendix. 

(3) Perforative appendicitis, in which there is local destruction of 
all the coats and communication with the peritoneal cavity, is due to 
a sudden and virulent infection or an acute exacerbation of a slum- 
bering process and begins abruptly with intense pain; and in a short 
time ends in peritoneal suppuration, local or general. 

(4) Gangrenous Appendicitis. — This form, beginning as such, is 
the most treacherous, for often the symptoms are in no wise pro- 
portionate to the seriousness of the case. Death is impending, and 
yet neither the pain, pulse, nor temperature gives due warning. 
There is absolutely no way at this present time by which the doctor 
may recognize this condition de novo. It may be imagined that such 
a condition arises from sudden interference with the blood current 
to the organ, while infection plays the lesser part. On the other hand, 
gangrene which ensues from virulent infection begins at once with the 
characteristic symptoms of appendicitis added to those of sepsis and 
peritonitis. 

It is from the point of view of these pathological variations that 
the most diverse opinions as to treatment have arisen. 

It is evident that nature, unaided, may be able to take care of the 
milder type. It is a clinical fact that nature by means of her own, 
may sometimes control and keep^the inflammation within bounds, 
even in the more dangerous cases. By means of plastic exudates, 
she walls off and limits the suppurating area and later provides a safe 
means of escape for the products of suppuration. But, unfortu- 
nately, such a happy issue can never be depended upon. On the 
contrary, the suppuration is more likely to become diffuse and there 
presents the picture of purulent peritonitis and the imminent prospect 
of a fatality. In such a case one loses sight of the local symptoms. 

The abdomen is rigid, tympanitic and everywhere exceedingly 
tender. The temperature is high; the pulse rapid; the tongue coated, 
brown and fissured; and as the disease progresses, the symptoms of 
36 



562 APPENDICITIS. PURULENT PERITONITIS 

circulatory collapse appear. The temperature then becomes sub- 
normal, the pulse almost uncountable, and the features pinched and 
anxious, until finally a mild delirium with pleasant hallucinations 
ushers in the end. 

The infection may be so severe, the toxemia so profound, that the 
patient may die of septic peritonitis before pus has had time to form. 
Indeed, death may come from sepsis before the ordinary signs of in- 
flammation appear. 

Such may be the outcome of what appears to be the mildest case. 
It is this prospect and the attendant uncertainties which have led 
many doctors to regard appendicitis as an emergency to be operated 
upon as soon as the diagnosis is made. As Pfaff, of Indianapolis, 
puts it, the difference between the mortality of 1 per cent, in the very 
early operations, and that of 15 to 30 per cent, in the abscess stage, 
is so frightful that, in comparison, an occasional unnecessary opera- 
tion is of no consequence at all. If we are to fulfill our obligations, 
we must act vigorously and to-day. 

This is undoubtedly a safe rule in the practice of the skilled opera- 
tor, who has at his command all the facilities of the aseptic operating- 
room and trained assistants. 

The case is quite different with the general practitioner, remote 
from these accessories. Moreover, it is known that 80 to 85 per 
cent, of these cases recover without operation. Even for the relaps- 
ing from, Treves says that much may be done by medical means, 
diet, attention to the bowels, and by placing the patient under con- 
ditions more favorable to a state of peace within the abdomen. 

Whatever may be proper in hospital practice, it certainly cannot 
be imposed on the general practitioner that he operate at once. 
Even in connection with the skilled surgeon, it may be said that his 
technic has not yet reached such a degree of perfection that an opera- 
tion is always safer than the milder form of appendicitis unoperated. 

The doctor then will face his responsibility, a heavy one truly, 
knowing there is much to be accomplished by medical means and 
yet hoping that he will have the judgment to recognize the failure 
of nature and of his art, and the will to resort not too late to more 
radical measures. 

Assume that the diagnosis is definitely made; assume that no sur- 



TREATMENT OF APPENDICITIS 563 

geon is within beck and call (for appendicitis is strictly a surgical 
disease), what will you do? It is evident at once that this is a clin- 
ical hypo thesis, and the question is to be resolved on a clinical i>asis. 

I. You see the case from the first. The attack begins mildly or 
with only moderate severity; there was perhaps a single attack of 
vomiting; the pain, abdominal tenderness and rigidity are not 
marked, and the patient's general condition is good. 

Under these circumstances, as Lejars says, it is perfectly legitimate 
to institute a medical treatment, in the meantime holding the case 
under the strictest surveillance. But this formula is null without 
the last provision. // the march of the disease cannot be watched, it is 
better to operate at once, and this rule may as well be made to apply 
to any case in which delay might otherwise be counselled. You 
decide to try medical treatment, but in what form? Like many 
others herein involved, the question brings forth a varied response. 

Under these circumstances one may follow the plan of "immobili- 
zation" which Lejars and others so highly praise. But to be effect- 
ive, it must be rigorously and consistently applied. 

Keep the patient absolutely quiet in bed. Give no purgatives — ■ 
and this means give neither calomel nor oil. Give no enemas. Sus- 
pend nourishment absolutely, relieving thirst by a few drops of water 
frequently given. 

Ice to the Abdomen. — Not a handful of ice in a little bag applied 
over the iliac fossa, but two or three large bags covering the whole 
abdomen below the umbilicus and refilled as the ice melts. 

Opium, in 3^-grain doses in pill form every two hours for an adult; 
but it must not be pushed to the point of annulling all pain and sus- 
pending the functions of the kidney. 

It is far from being the rule that the practitioner remote from the 
larger towns can have ice at his command. Likewise, opium in the 
hands of the inexperienced may be a two-edged tool. He must often, 
therefore, depend upon other modes of procedure, and for these, 
there is no lack of eminent authority. Under the circumstances in- 
dicated, begin with a single hypodermic of morphine if the pain is 
1 severe and with small doses of calomel (Ho~Ko g r frequently 
repeated, until a grain or two is taken; follow at the end of three 
hours with a large dose of castor oil or larger doses of albolene until 



564 APPENDICITIS. PURULENT PERITONITIS 

the bowels have moved freely. If the bowels are slow to move, 
supplement the internal remedies with enemas of normal salt solution. 
Give salol or carbonate of guaiacol every three hours. Apply hot 
fomentations to the abdomen, flannels wrung out of hot water and 
sprinkled with turpentine. Cover the hot flannels with several 
additional thicknesses and apply hot- water bottles filled with boiling 
water, and cover the whole to retain the heat. As the water cools, 
withdraw, one by one, the various layers so that the temperature 
may be maintained at the highest point of comfort. Hot kaolin 
cataplasms often render service. 

As Oschner commands, food must be withheld absolutely, and if 
there is much gastric disturbance or pain, the stomach should be 
washed out. Opium is contraindicated under this form of treat- 
ment, for it is the purpose to cleanse the bowel. 

McGrath, of New York, probably expresses the prevailing opinion, 
summing the matter up in this wise (Medical Record, Feb. 1, 1908): 

"Only in the catarrhal cases can there be any question as to treat- 
ment once the diagnosis is made; whether it is better to operate with- 
out delay or seek to avail oneself of the advantage of an interval 
operation. If sure of the character of the lesion, we may temporize; 
it will do no harm watching the patient carefully for any sign of 
danger. Many of these cases resolve without going on to suppura- 
tion or gangrene, and therefore escape operation during the acute 
attack. Nature may be assisted in her efforts at spontaneous cure 
in these cases by enjoining complete rest, withholding all food and 
permitting only water to be taken, and by small repeated doses of 
calomel and sodium bicarbonate. An ice-bag may be applied over 
the region of the appendix. But if there is any doubt as to the exact 
pathological condition, operation should be advised unless marked 
contraindications exist." 

George J. Cook, of Indianapolis, who has had as much experience 
with this disease as anyone in the Mississippi Valley, does not operate 
in mild attacks of primary appendicitis. If it is a second attack, he 
operates without delay. He says that not infrequently a mild catar- 
rhal appendicitis does not recur. In such cases, he puts the patient 
at rest. He unloads the bowels with enemas merely. If the attack 
follows overeating, he employs a mild saline primarily. Nothing but 



TREATMENT OE APPENDICITIS 565 

water is permitted. As an intestinal antiseptic, he gives 5 grains 
of carbonate of guaiacol three or four times in the twenty-four hours. 
If the patient should complain much, he gives small doses of opium, 
after the diagnosis is made. He gives it to quiet the pain and not the 
peristalsis, asserting that the bowel will of itself be quiescent if 
empty. Ice-bags applied to the abdomen as a routine measure repre- 
sents to him the chief element in the relief of pain and control of 
inflammation. 

Note that whatever the form of treatment, the case must be nar- 
rowly watched. If the pulse and temperature remain in harmony; 
if the abdominal tension and tenderness tend to grow less; if the 
bowels move and gas escapes per rectum; if the general condition is 
good; there is ground to expect a satisfactory termination, but no 
excuse to relax one's vigilance. 

No nourishment should be given by mouth until defervescence is 
complete, and after that a liquid diet should be maintained for one to 
two weeks, depending upon the severity of the attack, and rest in 
bed as well. At the end of a few weeks, the appendix should be 
removed. 

But the progress of the disease may suddenly change. All the 
symptoms may become aggravated and the dangerous nature of the 
case become at once obvious — immediate operation is indicated; 
or the change may be insidious (unsuspected by the careless observer) 
and in this instance the chief reliance must be placed upon the pulse. 
If the pulse is rapid and weak with a falling temperature, or if the 
pulse falls to 50 or 60 with a rising temperature; in other words, if 
there is any marked divergence between pulse and temperature, 
again the indications are to operate at once. To repeat, any marked 
aggravation of the symptoms after improvement once begins, or the 
occurrence of any marked disparity between pulse and temperature, 
however benign the other symptoms may be, are indications for 
operation without delay. 

II. Another case: You have watched the case, but the tempera- 
ture has persisted, and beyond, say the sixth day, when there should 
be a marked improvement, you find the temperature rising or 
fluctuating, the pain increasing, a tumor forming most painful at its 
center. In this case also the indication is for immediate operation. 



566 APPENDICITIS. PURULENT PERITONITIS 

III. Suppose you see the case only at the end of several days, dur- 
ing which time the disease has run a neglected course. May one at 
this time, with any effect, apply a medical treatment, or should one 
resort at once to an operation? The question can only be answered 
after a careful consideration of the history of the case, such as the 
patient or his attendants can give, and a thorough investigation of 
the present symptoms. Only when the case is obviously benign can 
one take the responsibility of further delay. For example, if the 
pulse and temperature are in accord, if the tenderness and tympanites 
are diminishing, then nothing better can be done than to follow the 
rules with regard to rest and diet already laid down. Yet one must 
be ever mindful of the treacherous character of certain forms of 
septic attack. 

Again, you find the disease progressing and in the active stage of 
the third, fourth, or fifth day, with no indications of beginning im- 
provement, but the symptoms are not aggravated, and there is a 
plastic exudate without softening: again it may be said that under 
these circumstances it is legitimate to wait. 

Any continuance of the fever beyond the eighth or tenth day, even 
though the pulse is good and the exudate has not softened, is a matter 
of grave suspicion, and with the least enlargement of the tumor or 
disturbance of pulse, operate without delay, and it is more than 
likely you will find a large abscess. 

IV. In any case, at any stage, if a diagnosis of abscess can be made 
out — a palpable fluctuating mass, in the iliac fossa — whatsoever the 
other symptoms may be, there is but one indication, immediate 
operation. No practitioner to whom the task falls, whatsoever his 
ability or training, can do anything else and do his duty. Even 
though you cannot detect fluctuation, but by vaginal and rectal 
examination determine that the mass is doughy and painful, operate 
and you will almost certainly find pus. 

V. Finally, even if the case has progressed to a general peritonitis, 
it is one's duty to operate unless the patient be practically moribund, 
and even in these cases, as Lejars puts it, operation has rescued a 
certain number of patients from the very jaws of death, for without 
operation they would inevitably have died. 

Even though the diagnosis is not definitely established and one 



APPENDECTOMY 567 

considers the possibility of meeting with a tubercular peritonitis or a 
salpingitis or similar condition, yet the rule should be to operate in 
any case of doubt. 

Operation. — Two operations will be described: A, when no pus or 
other complications are expected; B, when pus, localized or diffused, 
is a certainty. 



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Fig. 421. — Vertical incision through skin, aponeurosis and sheath of rectus. Outer border 

of rectus exposed in bottom of wound. 

A. Incision. — Begin i inch above or 2 inches below the line con- 
necting the anterior superior iliac spine with the umbilicus. The 
incision crosses this line J^ i nc h to its inner side of its middle point 
and follows, practically, the outer border of the rectus abdominis. 



568 



APPENDICITIS. PURULENT PERITONITIS 



Divide first the skin and fat and expose the aponeurosis of the 
external oblique. Divide next the aponeurosis and under one lip is 
the edge of the rectus, and under the other, the transversalis (Fig. 
421). Split the sheath of the rectus and retract the edge of the rec- 
tus exposing the transversalis fascia. 





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Fig. 422. — Rectus drawn inward. Posterior layer of sheath and transversalis fascia 
divided. Peritoneum exposed and cone lifted preparatory to dividing. 



Divide the transversalis fascia, exposing the subperitoneal fat 
and pick up a fold of the peritoneum, and divide it, turning the cut- 
ting edge of the knife away from the abdomen (Fig. 422). Usually 
the great omentum will bulge into the wound after the peritoneal 



APPENDECTOMY 



569 



incision is enlarged. Replace the omentum and, if necessary, hold 
it with a gauze pad. 

Next introduce a finger and feel for the cecum, which will be rec- 
ognized by its bands, and pull it up into the wound until the base 
of the appendix can be seen. The appendix may be adherent, and 





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Fig. 423. — Appendix and part of cecum delivered and walled off with gauze. 



the adhesions should be broken up very gently. Once the appendix 
is freed, it is to be brought up out of the wound and the cecum re- 
turned to the abdominal cavity and walled off with gauze pads 
(Fig. 423). 



57° 



APPENDICITIS. PURULENT PERITONITIS 



Tie off the meso-appendix with catgut, and cut it away from the 
appendix close to its line of attachment. 

An incision is now carried around the base of the appendix, divid- 
ing only the serous coat, which is stripped back toward the cecum, 
forming a peritoneal cuff (Fig. 424). The appendix is now ligated 



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Fig. 424. — Peritoneal cuff turned back; appendix ligated and amputated. 



and cut off, the mucous stump touched with carbolic acid and then 
with alcohol. The peritoneal cuff is drawn over the stump and su- 
tured. The stump is now invaginated and buried with a row of 
Lembert sutures. The gauze pads are removed with the exception of 
one, which covers the cecum until the last stitches are placed in 



*■ 






APPENDECTOMY 



571 



peritoneum. Repair by separate lines of suture the peritoneum, 
transversalis, aponeurosis, and skin. Drainage is unnecessary. 

B. The incision, 4 inches long, is a finger's breadth to the inside 
of the anterior superior iliac spine, with its middle corresponding to 
the spine (Fig. 425). 

The first incision traverses the skin and superficial fascia, which 
are likely to be very vascular in such a case. The external oblique 
appears, its fibers parallel with the incision. Divide it the whole 





Fig. 425. — Appendicial incision. (Veau.) Fig. 426. — The external oblique divided; 

the internal oblique exposed. (Veau.) 



length of the wound and catch the edges with forceps which will serve 
as retractors (Fig. 426). 

Next divide the internal oblique and transversalis muscles, whose 
fibers run transversely. The layer is thick, and several vessels will 
need to be caught (Fig. 427). 

Retract these layers and the transversalis fascia is exposed. This 
you divide, bringing into view the peritoneum. 

Catch up a fold with the forceps, and divide its base with the 
scissors (Fig. 428). From the small orifice thus created, there flows 
a seropurulent fluid. Enlarge the peritoneal opening and hold back 
the intestine with compresses. Examine the cavity. It may be 
that the omentum, thickened and infiltrated, will cover the field, 
but do not disturb it. 



572 



APPENDICITIS. PURULENT PERITONITIS 



Follow with the index finger the wall of the fossa until the cecum 
is reached. Wiping out the cavity, you may be able to see the bands 
of the cecum, which are to be followed downward by sight and touch, 
for they lead to the appendix. 

Remove the appendix if possible. You may not be able to find it, 
but do not prolong the search and certainly do not break up adhesions 
in this search. 

When it is located, gently draw it to the surface. It is exceedingly 
friable and should not be ruptured. Throw a catgut ligature about 
its base close up to the cecum and tie moderately tight (Fig. 429). 




Pig. 427. — The two oblique muscles incised, 
the trans versalis exposed. (Veau.) 



Fig. 428. — Showing the three muscular 
layers and the peritoneum incised. (Veau.) 



Amputate the appendix, and if there is no bleeding cut the liga- 
ture short. Determine now the character of the suppuration, 
whether circumscribed or diffuse (Fig. 430). 

(a) It is Circumscribed. — Wipe out the cavity very carefully with 
sterile gauze. Do not irrigate. Place a drainage-tube upward 
toward the diaphragm (Fig. 431). Do not use violence. There a 
new collection of pus may be found. Pass a second drainage-tube in 
the same manner down into the pelvic cavity. This is the most 
important, for the fluids tend to collect there. Leave the third in 
the iliac fossa and the fourth directed toward the middle of the 



APPENDECTOMY 



573 



abdomen. Secure each with a safety-pin. Suture up to the 
drainage-tubes, so that the opening will be only large enough to ac- 
commodate the tubes. 

If the patient is a female, after wiping out the cavity carefully, a 
counter-opening may be made into the vagina in favorable cases, and 
with efficient drainage secured by that route, the abdomen may be 
completely closed. 




Fig. 429. — Throwing a ligature around base of sloughing appendix. (Veau.) 



In many cases even without such drainage, the abdomen may be 
closed after cleansing the cavity, but it cannot be advised in the 
emergency wort of general practice. 

(b) The Suppuration is Diffuse. — Make a second incision from the 
umbilicus downward for a couple of inches, which is sufficient. 
When the peritoneum is opened, the fingers can touch through the 
two openings. 

If the pus seems to have reached into the left side, it may be advis- 
able to make a third incision over the left iliac fossa. Through these 
incisions irrigate the abdominal cavity with normal salt solution, 
using plenty, 3 or 4 quarts, and continue the irrigation until 
the fluid flows out clear. Unless it be complete, reaching every part 
of the cavity, irrigation had better be dispensed with. The addi- 



574 



APPENDICITIS. PURULENT PERITONITIS 



tional incisions may even be unnecessary if the following treatment is 
pursued: 

The patient is now put in the Fowler position and a continuous rec- 
tal enema of normal salt solution arranged for. The purpose of this 
treatment, instituted by Murphy with such signal success, is to secure 
a constant saline lavage of the peritoneal cavity. In other words, 
the fluid passes from the bowel into the peritoneal cavity, accom- 




Fig. 430. — Diagram showing directions the pus may extend. 

C, iliac. (Veau.) 



A, Sub-hepatic; B, pelvic; 



plishes its healing mission, and drains out through the abdominal 
wound. 

The fluid should be maintained at a temperature of ioo° F., and 
should be allowed to flow into the rectum at the rate of 1 pint per 
hour or thereabout. The patient's sensation should be consulted. 
If there is a feeling of tightness and distress, the flow should be les- 
sened. After 2 or 3 quarts have been introduced, the flow 



DRAINAGE 



575 



should be shut off for an hour or two. The injections may be con- 
tinued one to three days. 

Moynihan reviews his experiences with this treatment (Lancet, 
Aug. 17, 1907) and concludes that it has exceptional value. He 
insists upon attention to the details of administration and describes 
the methods found most useful. The largest quantity of the solu- 
tion taken by any of his patients was 16 pints for the first 
twenty-four hours, and a total of 29 pints in three days. He 




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Fig. 431. — Placing a tube in the sub-hepatic space. (Veau.) 



emphasizes the character of improvement in the appearance of the 
patient, in his pulse and temperature, and in the action of kidneys 
and skin. 

The plan pursued by others aims to secure drainage by means of 
tubes passed in various directions into the intestinal mass and into 
the pelvic cavity. Under these circumstances, the enemas of nor- 
mal salt solution should be used at intervals and the dressings 
changed on the second day. On the fifth day, the tubes should be 
removed, cleansed and replaced exactly as before. The patient 
must not strain while this change is being made and children may 
need to be given a few whiffs of chloroform. Cleanse the drainage- 



576 APPENDICITIS. PURULENT PERITONITIS 

tubes every third day, gradually shortening them as granulation 
proceeds. 

If a new focus of infection forms, if the temperature reaches beyond 
1 01 ° in the evening for two or three evenings, no matter what it was 
in the morning, one may be sure of suppuration somewhere. It will 
be necessary to re-operate and re-establish drainage. 

Septic peritonitis , originating elsewhere than the appendix, ought 
to be similarly treated, but the results are so discouraging that the 
operation cannot be urged upon the general practitioner, however 
advisable it may be in hospital practice. 

The principle of treatment is the same. Make a median incision 
below the umbilicus and search for the cause. It may originate from 
a ruptured Fallopian tube, it may follow perforation of the stomach 
or duodenum, and the break must be located and repaired. It may 
follow the perforation of typhoid fever and for this condition, the 
operation will be done more and more as time goes by. 

Gerster, of New York, before the 1909 Congress at Budapest, sum- 
marizes the treatment of diffuse free progessive peritonitis thus: (1) 
Preliminary lavage of the stomach; (2) anesthesia by nitrous-oxid 
gas followed by ether; (3) rapid exposure of primary focus of infec- 
tion; (4) stoppage of visceral leak by suture or tamponade; (5) 
gentleness and rapidity of procedure, avoidance of friction by wiping, 
etc.; (6) no irrigation; (7) soft rubber- tube drainage of right iliac 
fossa and, if necessary, of Douglas' pouch; (8) closure of external 
wound by three layers of suture; (9) for paralytic ileus repeated 
gastric lavage, low and high enemata, or systematic rectal lavage, 
enterotomy by stab done in intractable cases only; (10) rational 
administration of opiates; (11) withholding of all ingesta while vom- 
iting is present; (12) Murphy's proctoclysis; (13) Fowler's position; 
(14) early incision and drainage of secondary abscesses; (15) laxa- 
tives, calomel and salts, to be given only after cessation of vomiting; 
(16) tampons used for walling off necrosed areas not to be disturbed 
without necessity till they become detached of themselves. 



CHAPTER IX 
ACUTE INTESTINAL OBSTRUCTION 

Acute occlusion of the intestinal canal is a condition always to be 
dreaded, for it begins suddenly and unexpectedly and, unless relieved, 
hurries to a fatal issue, due either to shock or sepsis. Perhaps, as 
Bloodgood says, the condition is not a frequent one, yet, none 
the less, it is an emergency whose character must be thoroughly 
understood. 

But for that matter its character is variable, depending upon the 
cause. To simplify the subject, the obstruction due to strangulated 
hernia is not considered here, for in such cases the cause of the ob- 
struction is quite obvious; nor need we consider post-operative ileus, 
for it has a pathology of its own; again the obstruction which may 
accompany appendicitis is in a class by itself. The acute obstruc- 
tions to be studied include those changes in the form or direction of 
the bowel, or those accumulations within its lumen, which completely 
and suddenly dam the fecal current. Whether it be a kink or twist 
in the gut; a volvulus or intussusception; an adhesive or constricting 
band, relict of a former peritonitis (Fig. 432) ; an accumulation of gall- 
stones or a cancer: whatever the source of the obstruction, the danger 
arises, as has been said, from two sources — shock and sepsis. By far 
the lesser of these two evils is shock. In many cases it may be ab- 
sent, and even when it is the dominant feature early in the attack, it 
may gradually subside. The sympathetic plexuses seem able to re- 
gain their balance and adjust themselves to new conditions. For this 
reason attacks, which begin with collapse, often seem to improve in a 
short time. But such improvement is deceptive, for sepsis pursues its 
insidious course, the bowel becomes more distended, its peritoneal 
coat more permeable, and so the intestinal bacteria find their way 
into the peritoneal cavity and their toxins into the blood. It is 
stercoremia, therefore, which is to be dreaded, for there is no way to 
measure its progress with any certainty. 

37 577 



578 



ACUTE INTESTINAL OBSTRUCTION 



J. R. Eastman reports a case which illustrates the deceptive char- 
acter of many cases of obstruction. The patient had undergone, 
some years before, three various abdominal operations. The at- 
tack came on suddenly, and on the third day the vomiting became 
stercoraceous. In preparing for the operation, high enemas were 
given, followed by escape of flatus. The operation was deferred, as 
the patient continued apparently to improve, the bowels moving, 
gas escaping freely, and the patient feeling quite comfortable. Two 




Fig. 432. — Intestinal obstruction due to band of adhesions. (Reed and Carnrick.) 



days after, however, the fecal vomiting re-appeared and with it all 
the ominous signs of obstruction. At the operation, 4 inches of 
small intestine, adherent in an inflammatory mass, was found to be 
gangrenous. Resection, anastomosis, recovery. It is»to be noted 
that the bowels had moved though the gut was strangulated and gan- 
grenous, the gas and fecal matter undoubtedly passing the point of 
strangulation. (Indianapolis Medical Journal, July 15, 1909.) 
The group of symptoms constitutes a very definite clinical picture: 



DIAGNOSIS OF OBSTRUCTION 579 

(a) pain, (b) tympanites, (c) vomiting, (d) constipation, and (e) 
collapse. 

(a) The pain develops suddenly and severely, often following 
some violent exertion, and takes the form of paroxysmal colic. 
There is localized tenderness. 

(b) Tympanites is marked, the whole abdomen being distended, 
and often, on this account, the respiration and circulation are im- 
paired. Peristalsis is exaggerated, and the violent movements of 
the bowel may often be noted through the abdominal wall. At the 
site of the greatest tenderness, a tumor may be found. 

(c) There is often at first a rumbling of the bowels and nausea, 
soon followed by an incessant and distressing vomiting, at first gas- 
tric and finally fecal. 

(d) Constipation is a constant feature, though at first there may 
be some movement from the lower bowel. In intussusception there 
is often all through the attack some discharge of bloody mucus and 
gas. This may be the case, too, in strangulation near the pylorus, 
but in such a case, the extreme distention of the stomach and the 
violence of its movements suggest the nature of the difficulty. 

(e) Collapse is imminent from the first, and is indicated by the 
weak, thready pulse, the rapid breathing, the pale, pinched features, 
and the anxious expression. 

These are the symptoms, whatever the form of the acute obstruc- 
tion, whether it be strangulation, intussusception, or volvulus, and 
very rarely can the form of the obstruction be definitely determined 
before the operation or post-mortem. 

Certain factors make one of the conditions the most probable. 
If it is a child under ten years of age, it is almost certain to be intus- 
susception; if there have been previous attacks of some form of 
peritonitis, strangulating bands of adhesions are likely to be present; 
if the patient is forty or fifty years of age, with a history of constipa- 
tion, volvulus suggests itself. 

In addition to noting the symptoms and history, a careful 
search must always be made by palpation for an abdominal tumor, 
and finally the investigation is terminated by rectal or vaginal 
examination. 

Treatment. — In the few hours that must elapse before one can 



580 ACUTE INTESTINAL OBSTRUCTION 

fully make up his mind that it is a case of acute obstruction, there 
are certain things to do, but, more especially, certain things not to 
do. Do not give purgatives. This is an axiom scarcely necessary 
to repeat. They can do no good and will most certainly do harm. 
Do not give large and repeated doses of morphine. It will help the 
patient to die easy, but in such a case, it is "not a remedy for the 
patient but a refuge for the doctor." It is doubtful even if it should 
be given at all. It is possible that minute doses may diminish the 
peristalsis, quiet the vomiting to some extent, relieve the shock a 
little, and ease the pain measurably without masking the true con- 
ditions, but under the circumstances, it is an edged tool. Give no 
nourishment by mouth. The two measures likely to be of the great- 
est benefit are gastric lavage and rectal injections. 

The gastric lavage may in some measure diminish the vomiting; 
and, in case an anesthesia is necessary, it may prevent asphyxia 
from a gush of vomited matter. 

Rectal enemas are sometimes effective in relieving the obstruction, 
but if used, it must be with the strict proviso that the injection be 
done carefully. If roughly given, if the fluid is thrown into the 
bowel with too much force, even if there is no danger of rupturing 
the bowel, it at least irritates it and defeats its own purpose. It is 
likely if the condition has existed more than twenty-four hours the 
enemata will be of no avail. 

There is a definite mode of procedure: put the patient crosswise in 
bed in the lithotomy position, with the pelvis turned slightly to 
the right side. Anoint the anal region well with vaseline, and also 
the rectal tube, which should be of soft rubber, 3 or 4 feet in 
length. In the case of an infant, a rubber catheter will serve. 
Guide the catheter with the left index finger, and as it enters the 
rectum direct it backward at first and then slightly to the left. 
Keep hold of the tube close up to the rectum, the better to control 
it. Push the tube a little at a time, and if it meets with the ob- 
struction, withdraw it slightly, and advance it with a boring move- 
ment. Any force may result in the tube merely coiling up in the 
rectum, the doctor in the meantime having the impression that it 
is ascending high in the bowel. Sometimes it is advantageous to 
let the injection flow as soon as the first part of the tube is intro- 



TREATMENT OF OBSTRUCTION 581 

duced, as by that means the rectum is dilated and Houston's valves 
are not so likely to intercept the tube. The tube must be introduced 
as high as possible without using force. In the great majority of 
cases it goes no higher than the sigmoid. 

Attach the fountain syringe, holding it low at first and gradually 
raising it to increase the pressure. It should not be raised much 
more than 3 feet above the patient's level. The quantity of 
fluid, either warm salt solution or oil, which may be injected, varies 
with the age, say 1 pint for the infant and 4 to 6 quarts for the 
adult. 

When the injection is completed, withdraw the tube rapidly, and 
lay the patient back in bed. The enema will be expelled sooner or 
later with severe colicky pains. If ineffective, it returns practically 
clear. If it has done good, it will be accompanied by flatus, and, 
at the last, there will be some hard lumps. The final evacuation 
may not take place for some time, but the escape of gas is a good 
indication that the obstruction has been at least temporarily 
relieved. 

If this has not done good, the enema should be repeated with the 
patient in the knee-chest position. 

Lejars recommends the " electric bath" as efficacious in many 
cases, but this treatment is scarcely applicable in general practice. 

On the whole, the treatment is surgical; and the doctor must have 
it on his conscience that if the case is acute obstruction, delay is 
dangerous or even fatal. The point is to make the diagnosis quickly, 
and when that is made, there is only one thing to do, operate. 

The practitioner will hesitate between two procedures, median 
laparotomy and artificial anus. 

Median laparotomy is the ideal operation. It, alone, is curative, 
for the cause of the obstruction is found and relieved; but it is deli- 
cate and dangerous. These are the conditions which Veau formu- 
lates, under which alone the doctor must undertake it: 

(a) The operator must be experienced and resourceful, for it is 
often difficult to locate the cause and equally difficult to remove it, 
and the distended bowel is always a source of embarrassment. 

(b) The operation must be conducted where there are the surgical 
accessories and capable assistants. 




5&2 ACUTE INTESTINAL OBSTRUCTION 

(c) The diagnosis must have been perfected, so that the operator 
knows about what he will have to do. 

(d) The patient must be vigorous and able to stand a tedious and 
prolonged operation. 

These conditions are nearly always lacking when the doctor is 
thrown absolutely upon his own resources, so it may be laid down as 
a rule that the general practitioner must choose the second pro- 
cedure. 

An artificial anus will usually save the patient's life and is within 

the skill of any doctor under almost any 
circumstances. After the patient has later 
regained his strength, the operation neces- 
sary to complete a cure may be under- 
taken. It will not be an emergency opera- 
tion, and the time and place may be chosen. 
To make a temporary artificial anus will 
be the proper procedure under the circum- 
stances indicated. There is a single nota- 

FlG ' 433 (^3r Pti ° n ' ble exce P tion: if the P atient is a child with 

an undoubted attack of intussusception, 

and if the enemas have failed to give relief, it is imperative to 

do a laparotomy (Fig. 433). 

LAPAROTOMY FOR INTUSSUSCEPTION 

Intestinal invagination or intussusception occurs only in the first 
years of life for the reason that^the mesentery lacks resistance at 
that age. It occurs at a point where a mobile part of the bowel 
joins a part more fixed and is most common at the ileocecal junction. 

As a result of colic or spasm the ileocecal valve protrudes into the 
cecum and is followed by the ileum and its mesentery which alone 
limits the extent to which the large instestine may swallow the small 
bowel. 

A thickened band or collar marks the line where the two parts 
come in contact, and this collar is usually tight; after a little while 
adhesions may here occur between the invaginating and invaginated 
parts. 



INTUSSUSCEPTION 583 

Here the strangulation occurs and the symptoms are proportional 
to the degree of strangulation and the rapidity with which it 
occurs. 

A case reported by Estes (American Journal of Surgery, August, 
1906) illustrates the subject and emphasizes the danger of expectant 
treatment. 

A girl of three years in fair health, three days before had been 
seized with violent abdominal pains with straining and tenesmus. 
At first the passages were fecal and then mucous, tinged with blood. 
She had intervals of apparent ease when she would play with her 
toys and ask for something to eat. After three days' treatment by 
enemas and light laxatives, she developed signs of complete obstruc- 
tion. The abdomen was distended, vomiting frequent and at last 
feculent; there was persistent pain, rapid, weak pulse, and general 
weakness. At this time Estes was called and found a very pale, 
emaciated, weak, suffering baby, with pulse 130, and temperature 
101 . She was vomiting every half -hour. No distinct tumor could 
be felt, but there was some thickening in the right iliac region. 
Through that night, while preparing for the operation next morning, 
she was given some strychnia and morphia and saline enemas, which 
produced an improvement. 

Operation — median incision. A hand passed into the right iliac 
fossae located the sausage-shaped tumor of an ileo-cecal intussuscep- 
tion. Turning the child to get the intestines out of the way, gentle 
milking motions were made and almost immediately the intussuscep- 
tion was reduced. Inspection showed a very much thickened and 
inflamed section of the ileum about 6 inches long. It was decided 
not to exsect the injured gut. The torn border of the mesentery 
was sutured, the peritoneal coat bathed with hot saline solution, 
dried, sprinkled with aristol and replaced, and the abdomen rapidly 
closed. The child made a rapid and uninterrupted recovery and 
has been quite well ever since. 

The principal steps in the operation are as follows : 

(1) Median laparotomy. Be careful in opening the peritoneum 
not to wound the distended bowel. Expect to find trouble in the 
management of the bowel. A skillful assistant is a great comfort in 
this matter. 



584 



ACUTE INTESTINAL OBSTRUCTION 



(2) Search for the obstruction. The obstruction is usually easily- 
found in intussusception. After the abdomen is opened, proceed 
directly to the right iliac fossa, having no fear to introduce the whole 
hand, if gently done. In any case the cecum is first to be examined, 
for by its condition one can determine whether the obstruction is in 
the large or small intestine. 

The sausage-shaped tumor (in the case of intussusception) is 
pulled up into the wound and its topography carefully noted and 
the integrity of the gut determined. If there are no adhesions, if 





\ 








x^ 




\ 





Fig. 434. — Senn's method of performing taxis in reducing an invagination. 



there are no appearances of gangrene; in other words, if the accident 
is recent, try to reduce the bowel. 

(3) Disinvaginate, following the procedure of Senn, which has 
for its aim first to reduce the edema. This is to be accomplished by 
steady and uninterrupted manual compression of the tumor. 

As soon as the swelling is reduced, grasp the bowel below the tumor 
and press gently but firmly against the apex of the intussusceptum, 
at the same time making easy traction at the other end (Fig. 434). 
Remember it is easy to tear the bowel or mesentery. 



INTUSSUSCEPTION 



585 



When the bowel is reduced, examine again for gangrene. If 
there are points of disintegration, cover them in by Lembert sutures. 
If the whole segment of the bowel is gangrenous, it must be resected; 
or if doubtful, retained in the wound for further inspection. If the 
bowel is not impaired, wash and return; and the operation is com- 
pleted by the repair of the abdominal wall. 

If, as Senn says, repeated attempts at reduction fail, one of two 
courses must be pursued: the establishment of an intestinal anasto- 
mosis or resection of the invaginated portion; but the latter, on ac- 




Fig. 435. — Intussusceptum 
(Guibe.) 



exposed. Fig 436. — Intussusceptum resected. 

{Guibe.) 



count of the time required, must not be undertaken unless the 
i invaginated parts are gangrenous. 

The anastomosis between the parts of the bowel above and below 
the invagination may be accomplished by suture or the Murphy 
button. The technic of resection of the invaginated portion is 
represented in Figs. 435, 436, 437, and 438. 

The predisposing cause of these attacks of intussusception is often 
] acute indigestion. 

The pain, which is the first symptom, is often merely colicky at 
first, but later may be persistent. Vomiting is common but not 



5 86 



ACUTE INTESTINAL OBSTRUCTION 



nearly so severe as in other forms of obstruction, nor does it appear 
so early. The temporary relief following the vomiting is character- 
istic of intussusception. The nearer the duodenum the invagination 
is situated, the more severe the vomitus. Rigidity is not an early 
symptom. Distention is absent until^late. Tenderness is also a 
late symptom; indeed, in the early stages, pressure may give relief. 
The presence of a tumor is of great diagnostic value; it is usually 
movable, hard, and resistant. Its size gives no idea of the amount of 





Fig. 437. — Anastomosis after resection. 
(Guibe.) 



Fig. 438. — Repair of the bowel and appli- 
cation of Lembert sutures over the site 
of anastomosis. (Guibe.) 



bowel involved. Tenderness is a severe and early symptom; thirst 
not marked. Early diagnosis and early operation are the life-saving 
factors in these cases. 



POST-OPERATIVE ILEUS 

The acute obstruction of the bowel which may — which too often 
does — follow laparotomy is one of the tragic accidents of surgery. 
An operation of comparative simplicity may terminate uneventfully; 
the patient rallies from the anesthetic, seems to feel well, and with 






POST- OPERATIVE ILEUS 5S7 



the family is happy at the thought of danger passed. Twenty-four 
hours pass and it is noticed that the temperature falls to subnormal 
perhaps, and then begins slowly to rise. The pulse, at first 90 to 
ioo and of fair volume, slowly increases in rate while decreasing in 
force. The patient's mind, perfectly clear in the first instance, 
begins in a little while to be disturbed, and he grows anxious as to 
the outcome or perhaps calmly forecasts the end. 

In the meantime the tympanites has become marked, but no gas 
passes per rectum; and there is no sign of movement or peristalsis, 
in the distended gut. The pain is not severe, the chief distress is 
want of air; the patient complains that he cannot get a good breath; 
nausea develops, and finally continuous vomiting. If, now, the 
ordinary means of relief of gaseous distention fail and the symptoms 
do not in any respect improve, one may conclude that he has to deal 
with an intestinal paralysis. In simple tympanites the pain is 
colicky in its nature, there is little disturbance in pulse and tempera- 
ture, the vomitus is more nearly normal in character. But in spite 
'of these distinguishing features, it may be impossible to say, during 
the first few hours, whether the obstruction is serious or not. In 
any event, certain measures should be employed: If there is much 
nausea or any evidence of gastric dilatation the stomach should be 
washed out and %o grain calomel given every half-hour for at least 
ten doses. At the other end of the alimentary tube, the attempt at 
: relief is begun with an ordinary soapsuds enema. If no flatus passes, 
a Watkin's enema is next to be tried, or one which consists of 

Magnesia sulphate, 
Glycerin, aa 5 ij 

# Turpentine, 5j 

A large tube should be employed, but no effort made to introduce 
it high. Elevate the hips and inject the fluid slowly, and thus let it 
find its own way up the bowel. If gastric lavage and the persistent 
use of enemas fail to give any relief, if the judicious use of hypodermic 
injections of morphin and atropia, eserine, and pituitrin are with- 
out effect to awaken the intestine or to sustain the patient's vitality, 
' the only thing left which offers any hope is an enterostomy. This 
1 may be done under local anesthesia. The bowel through this open- 



588 ACUTE INTESTINAL OBSTRUCTION 

ing is to be kept washed out with normal salt solution. By this 
means the toxemia may be kept under control until the patient's 
forces rally. 

But, after all, the chief treatment of post-operative intestinal paral 
ysis is prophylactic and preventive. By washing out the stomach, 
by having the bowel well emptied with castor oil, by treating the 
exposed gut with scrupulous care, one may hope to reduce these 
accidents to the minimum. Slight traumatisms of the mesentery 
in the course of the operation, slight infections introduced in the 
clean cases are at the bottom of these surgical disasters. If they 
result from infections already fixed upon the peritoneum before 
operation, the surgeon may have a balm for his conscience but no 
excuse to relax his precautions. 

In all operations in which there is a diffused peritonitis in order to, 
prevent post-operative ileus, Heile injects 50 to 100 c.c. castor oil in a 
loop of the small intestine. The puncture of the gut is closed by a 
small silk suture. He claims excellent results. (Zeitblatt f . Chirurg. 
Leipsic, July 31, 1909.) 



CHAPTER X 
ARTIFICIAL ANUS: TEMPORARY; PERMANENT 

TEMPORARY ARTIFICIAL ANUS— ENTEROSTOMY 

An acute obstruction of the bowel may necessitate a temporary 
drainage through the abdominal wall. This will be the case when 
circumstances such as environment, lack of experience, assistance, or 
equipment preclude a laparotomy; or even when a laparotomy is 
done and it is found impossible at the time to remove the cause. 
. Enterostomy is therefore a life-saving operation which every 
practitioner must know how to perform. 

The operation proposes opening the abdomen, anchoring a loop of 
intestine in the abdominal wound and opening this loop to secure 
drainage. The incision will be made ordinarily in the right iliac 
fossa and the opening in the bowel made above the obstruction. 
For that matter, one need scarcely fear that he will open into the 
bowel below the constriction, for it is only the distended portion that 
will present. It is preferable to open the cecum, but if it is not avail- 
able, whatever loop presents will do. 

No special instruments are required. It is a good idea to have 
several needles already threaded with silk No. o or No. i. Local 
anesthesia may suffice. 

Incision. — Begin by dividing the skin and fat along a line two 
fingers' breadth from the anterior superior iliac spine, parallel with 
the fibers of the external oblique — an incision about 3 inches long, 
whose central point corresponds to the anterior superior iliac spine 
(Fig. 439). Catch up the two or three bleeding points. 

This first incision exposes the external oblique (Fig. 426) and the 
second divides that muscle in the same line. Catch up the edges of 
;the divided muscle. In the same manner, the third incision divides 
the internal oblique and transversalis, and finally exposes a fibrous 
layer, the transversalis fascia, which is carefully divided in order to 

/ 589 



59° 



ARTIFICIAL ANUS! TEMPORARY; PERMANENT 



reach the peritoneum (Fig. 428). Pick up a fold of that membrane 
with the dissecting forceps and incise it at its base, remembering 
that the distended bowel is in close contact (Fig. 422). 

A reddish fluid escapes as soon as the peritoneum is opened; seize 
each lip with forceps and enlarge the opening, but not to the full ex- 
tent of the skin wound. Restrain the bulging gut with compresses. 
Introduce the index finger and examine in various directions for a 
source of obstruction. Happily it may be found and relieved with- 





Fig. 439. — Trace of incisions for artificial 
anus: on the right, temporary; on the left, 
permanent. (Veau.) 



Fig. 440. — Locating the cecum. (Veau.) 



out loss of time. Usually, however, it will not be and one must not 
persist in his search or effort at relief. Attempt next to locate the 
cecum, passing the index finger down into the iliac fossa, following 
the external wall (Fig. 440). 

If successful in locating it, pull it up into the wound with index 
finger and thumb and hold it with two artery forceps. It is easily 
identified by the appendices epiploicae and by its bands. If the 
cecum cannot be reached, employ any loop which presents. 

Anchor the bowel. The bowel is sutured to the abdominal wall 
in this manner: Commence at one angle, passing the needle through 



TEMPORARY ARTIFICIAL ANUS 



S9i 



the parietal peritoneum of one side, through the serous and muscular 
:oats of the bowel, and through the peritoneum of the opposite side. 





Fig. 441. — Attaching the bowel in the angle Fig. 442. — Attaching the bowel laterally. 
of the wound. (Veau.) (Veau.) 





Fig. 443. — Diagram showing disposition of Fig. 444. — Opening of the bowel with 
sutures. (Veau.) thermocautery. (Veau.) 

Tie, but do not cut the threads (Fig. 440). Now make on each side 
three or four "U" sutures 3^ inch apart in this manner: the 
needle passes through the parietal peritoneum, the mucous and 



592 



ARTIFICIAL ANUS: TEMPORARY; PERMANENT 



muscular coats of the bowel, and out through the parietal peritoneum 
of the same side. Do the same on the opposite side (Fig. 442). 
Collect the loose ends of the sutures of the same kind in one forceps. 
In placing the sutures, do not let the protruding segment of bowel 
get folded or wrinkled. 

Suture the remaining angle in the same manner as the first and 
complete the repair of the peritoneal wound. The loop of bowel 
may not occupy all of it and these peritoneal sutures are cut short at 
once. (The relative position of the sutures is represented in Fig. 443.) 

Now repair the superficial wound by interrupted sutures in two 





Fig. 445. — Temporary artificial anus. 
(Veau.) 



Fig. 446. — Incisions for temporary and 
permanent artificial anus. (Veau.) 



layers, one reuniting the muscles and fascia; the other, the skin. 
The opening left immediately over the anchored gut is about an 
inch in length. Cut the threads short. 

Open the bowel. This is reserved for the last, and here the long 
threads of the lateral bowel suture, left until this time, are used to 
pull the bowel well into view (Fig. 444). Incise it with the bistoury 
for about an inch, and there is an immediate escape of gas. 

Cut short all the sutures. The bowel will not immediately empty 
itself. It will require possibly twenty-four hours, during which time 
the dressing should be changed every half -hour, afterward twice 
daily is sufficient. 



PERMANENT ARTIFICIAL ANUS 



593 



Remove the cutaneous sutures on the sixth day, else later they will 
become septic. Apply ointments to the inflamed skin. 

When the bowel is once emptied, which may require as long as 
twenty-four hours, seek to locate the site of the obstruction and to de- 
termine its nature. See if an enema will find exit at the wound or if 
an injection at the wound will discharge per anum (Fig. 445). A 




Fig. 447. — Opening the peritoneum. (Guibe.) 



month later when the patient has regained his strength, if the bowel 
has not become normal, send him to a specialist. 



PERMANENT ARTIFICIAL ANUS 

This operation, palliative in the treatment of cancer of the rectum, 
comes within the scope of every doctor. It may even be regarded as 
an emergency. There may come a time in the history of the case 
when the content of the bowel can no longer pass and the pain is un- 
! bearable. Then the operation will give great relief. The patient 
• suffers little pain after the operation, gains in weight, believes that he 
is going to get well, and so dies happy. 

In this case, the opening is to be in the sigmoid; it may need to be 

' 38 



594 



ARTIFICIAL ANUS: TEMPORARY; PERMANENT 



large. The bowel is completely divided transversely and the two 
ends anchored separately in the wound. 




Fig. 448. — The sigmoid flexure drawn out through the incision. Note the appendices 

epipjoicae, (Veau.) 




Fig. 448. — A forceps used to make an opening in the mesentery. {Veau.) 

The operation is best done in two stages. In the first, the sigmoid 
is drawn out and permitted to acquire adhesions. Subsequently the 
loop is resected. 



PERMANENT ARTIFICIAL ANUS 



595 



First Stage. — An incision 2 inches in length is made obliquely 
over the left iliac fossa, a couple of fingers' breadth within the an- 
terior superior spine. The lower end of the incision reaches to just 
above the level of the spine (Fig. 446). Dividing the skin and cellu- 
lar tissue, there will be some small vessels to ligate. The fibers of the 




Fig, 450 



, — Bowel retained by strip of iodoform gauze. (Veau.) 



external oblique appear, running parallel with the incision. Separa- 
rate them in the line and length of the skin incision by blunt dissec- 
tion. Widely separate the two portions of the muscle with retractors. 
In the bottom of the wound are seen the fibers of the internal 
oblique and transversalis which lie at right angles to the external 
oblique. Open through them by blunt dissection in the direction of 
their fibers and retract (Fig. 447). 



^$k 




Fig. 451. — Dividing the loop with the thermocautery. (Veau.) 

Divide the transversalis fascia and expose the peritoneum. This 
is opened and its lips seized with the forceps. Remove the retractors 

Search for the sigmoid. Introduce the index finger into the iliac 
fossa, following the posterior wall until arrested by the meso-sigmoid. 
In this manner locate the sigmoid flexure, and with finger and thumb. 



596 



ARTIFICIAL ANUS! TEMPORARY; PERMANENT 



draw it to the surface by gentle but persistent traction. It can be 
felt to yield. Once the loop is exposed, the only difficulty is over- 
come. The sigmoid is identified by the appendices epiploicae 
(Fig. 448). 

Spread out the gut and find the least vascular part of the exposed 
mesentery and this part transfix (Fig. 449) with a closed forceps. 
Opening the forceps, let it seize a roll of iodoform gauze of the caliber 
of the index finger and draw it into place. It will hold the bowel in 
position (Fig. 450). 





Fig. 452. — Upper orifice com- 
municates with bowel; lower with 
rectum. (Veau.) 



Fig. 453. — Permanent artificial anus. 
External opening of bowel with spur 
leading to rectum. {Veau.) 



If the cutaneous wound is too large and does not fit closely to the 
projecting loop, it may be diminished by a suture or two. 

Dress with sterile gauze and do not change until ready to resect, 
unless the dressing becomes loosened or soiled. Keep the patient 
on a light diet, chiefly milk. 

Second Stage. — Resect the bowel. On the second or third day, when 
the bowel has acquired adhesions, return with a thermo-cautery and 
artery forceps; there might be an arteriole to ligate. No anesthesia 
is necessary, for the gut is quite insensitive. 

The thermo-cautery is heated to a dark red (if at a white heat, 
there may be a little bleeding), and with it the bowel is completely 



PERMANENT ARTIFICIAL ANUS 597 

divided. Do not stop until the roll of iodoform gauze is completely 
exposed. The few minutes required will necessarily seem a long 
time, but do not get disturbed (Fig. 451). When the section is 
complete, the gauze may be readily removed (Veau) . 

Apply a dry dressing. On the second day give a laxative. After 
a while the patient will be able to regulate his passages to a degree. 

Through the lower orifice the cancer may be douched and the 
fluids will find their way out per anum (Figs. 452, 453). 

Do not neglect to warn the family that the end must come within 
from eight to fifteen months. As for the patient, it were better to 
ease his mind by vague references to the future closure of the wound 
so repulsive to him. 



CHAPTER XI 
STRANGULATED HERNIA 

What doctor in general practice has not had his experiences with 
strangulated hernia? And how many have escaped the conviction 
that it is an emergency deserving its evil fame? 

But, after all, its sinister reputation our predecessors have be- 
queathed us and, along with it, interminable discussions touching the 
agent of constriction and the indications for taxis. 

To-day we reverently lay aside those old notions, for we know that 
no other equally dangerous condition yields better results to appro- 
priate treatment. By " appropriate treatment " is meant early opera- 
tion. The indications for operation there is no need to discuss, for 
operation is always indicated. 

Taxis is an exceptional procedure, permissible only as a tentative 
measure under certain well-defined restrictions; and even then to be 
used with fear, for who can certainly tell that he has not reduced a 
gangrenous and perforated gut; and who but the most experienced 
may not be misled by certain forms of incomplete reduction? 

The danger from strangulated hernia was formerly supposed to 
arise solely from interference with the circulation and the consequent 
gangrene of the incarcerated loop, and the attention was centered 
chiefly upon the mechanical element. It was perhaps legitimate 
upon that hypothesis to treat expectantly or by repeated efforts at 
taxis an incompletely strangulated hernia. 

But now it is definitely determined that the chief source of danger 
is septic absorption, and in a given case long before the incarcerated 
bowel has ceased to be viable, the patient may be overwhelmed by 
toxins of a virulent type. It is this systemic poisoning that makes 
strangulated hernia dangerous, and which especially makes the 
operation dangerous. It is for that reason that procrastination is 

598 



DIAGNOSIS OF STRANGULATION 599 

so often fatal. So frequently it happens with these attacks that after 
hours of waiting, or after repeated efforts at reduction, the patient is 
finally turned over to the operator; and though the operation be of 
short duration and simple, yet the patient dies, for the reason that 
his powers of resistance were paralyzed by sepsis unsuspected. He 
was a veritable victim of delay. 

The thought to be kept uppermost, then, in treating strangulated 
hernia is not so much that the bowel is becoming gangrenous as that 
sepsis is imminent. 

The diagnosis is not difficult, as a rule. Usually the patient is 
known to have a hernia; suddenly it becomes painful and irreducible; 
the bowels refuse to move and become tympanitic; nausea and vom- 
iting ensue; and there are signs of circulatory depression. The gen- 
eral symptoms are, in fact, those of intestinal obstruction. The face is 
drawn and pinched, the lips white and the eyes sunken. There is a 
clammy sweat. The symptoms may all be mild at first, especially 
when the obstruction is not complete, or in the aged or debilitated, 
or if the bowel is surrounded by omentum which at first bears the 
brunt of the compression. It must be kept in mind that this mild 
onset may be wholly deceptive. 

It may be necessary to distinguish between an inflamed and ob- 
structed irreducible hernia on the one hand and strangulated hernia 
upon the other; in the first, pain and vomiting are not so severe, 
there is no collapse, and an impulse in coughing can always be 
detected. If a hernia was not before suspected, a careful examina- 
tion for one must be made in cases of intestinal obstruction. Small 

, sciatic or obturator herniae are easily overlooked. This is likewise 
true of small femoral hernia in fat subjects. 

Torsion of the spermatic cord or strangulation of an undescended 

* testicle may simulate strangulated hernia, but the indurated and very 
painful inguinal tumor, together^ with the 'cryptorchism, should 
suggest the nature of the attack. 

As Senn says, the differential diagnosis between a suppurative 

l lymphadenitis in the groin and a strangulated inguinal hernia may be 

' very difficult. He points out the necessity for caution in using the 
knife if the inflammatory swelling is single and occupies the site of 
a femoral hernia. In such a case the supposed gland should be 



600 STRANGULATED HERNIA 

approached by a careful dissection. If it proves to be a hernia no 
harm is done. 

An accumulation of peritoneal fluid in the imperfectly closed proc- 
essus vaginalis in the very young may give rise to symptoms of 
strangulation, but strangulated hernia is rare in infants. In such a 
case, inversion of the patient for a few minutes will often empty the 
sac and clear up the diagnosis. 

As has been said the indication for treatment is operation as soon as 
the diagnosis is made. There are, however, exceptional instances in 
which judicious efforts at taxis may be applied without greatly 
prejudicing the prognosis. But it is recommended without enthu- 
siasm and only out of due respect to those circumstances of time and 
place which seem to preclude immediate herniotomy. 

Taxis and operation, then, represent the sole measures of relief. 
Certainly no doctor at the present time would expect anything but 
harm from the use of drugs. 

As Senn says (Practical Surgery), no modern physician would for 
a moment consider seriously the therapeutic value of nauseating 
enemata, or the internal use of relaxing antispasmodic remedies, so 
much relied upon in facilitating taxis before herniotomy was shorn of 
its great mortality by the introduction of antiseptic surgery. 

Taxis, — Taxis, or the reduction of a hernia by methodical manipu- 
lation without instruments, is permissible only under these circum- 
stances: (a) The case is seen soon after the strangulation began; 
the hernia is of moderate size; the abdominal symptoms are not 
severe. 

(b) The patient is an old man debilitated, manifestly a poor sub- 
ject for an operation; he has had trouble before; it is only a few 
hours since his hernia became irreducible. 

Under these circumstances use taxis, and it will not be dangerous 
if properly applied and not repeated. The further proviso must be 
made that if it fails an immediate operation must be done. In the 
milder cases Senn advises that taxis may sometimes be facilitated by 
administering a dose of opium and giving a high enema. A full hot 
bath in many instances has an excellent effect. 

In the severer cases a general anesthesia is always required. Before 
beginning the anesthesia prepare the patient for operation so that 



REDUCTION BY TAXIS 6oi 

if taxis fails no time need be lost and a single anesthesia will serve 
both for the taxis and the operation. Chloroform is usually prefer- 
able to ether if it is expected that taxis will succeed. It permits 
a greater relaxation. 

Technic of Taxis: Inguinal Hernia. — Elevate the hips, flex and 
separate the thighs in order to relax the external ring. Grasp the 
tumor with the right hand (hernia on right side) so as to compress 
it uniformly with the tips of the fingers and thumb. Seize the 
neck at the external ring between the thumb and forefinger of the 
left hand. While the right gently compresses the tumor, the left 
empties the gut by stripping in the direction of the external ring at 
first, and later along the inguinal canal. The sole aim of this first 
maneuver is to empty the gut. The manipulations must be 
made methodically, without interruption and without force. If 
compression reveals the presence of a doughy mass, it is omentum, 
and as it probably occupies the lower part of the sac it will be better 
to compress nearer the neck in order to deal more directly with the 
intestine. Sometimes, to make traction on the tumor while the 
fingers at the neck continue the kneading will start the bowel con- 
tents toward the abdominal cavity. If the tumor under these manipu- 
lations grows smaller and softer, it is some guarantee of success. 
When the bowel is sufficiently emptied, it then becomes reducible 
and its return to the abdominal cavity is announced by a gurgling 
or a marked sense of yielding. 

When the bowel is reduced, the omentum, if present, should be 
returned in the same manner. One should not persist if the mass 
is thick and adherent for there is risk of rupture of an omental vessel, 
which may be followed by hemorrhage, all the more grave because 
unperceived. 

After the hernia is reduced the patient must be put to bed and no 
food by mouth permitted for at least twenty-four hours. Before 
getting about, a truss must be fitted. 

If after ten or fifteen minutes of gentle effort the hernial tumor 
remains unchanged in size and hardness, it is a waste of time to 
prolong the procedure. It cannot be said too often that repeated at- 
tempts are injurious, becoming with each repetition more and more 
harmful and illusory. 



602 



STRANGULATED HERNIA 



It may happen that after the hernia has been apparently reduced 
the symptoms of obstruction still persist, or even if at first relieved, 
appear again. The tympanites augments, the nausea and vomiting 
continue, and the signs of sepsis progress. It is evident that some- 
thing is amiss. One of several things may have happened, but no 
time is to be wasted in conjecture, for only the operation which must 
follow will definitely clear up the doubt. 

It may be that the hernial tumor has been reduced en masse. 
The hernial sac and its contents have been carried through the ex- 
ternal ring without having changed their relations and the constric- 




FiG. 454. — Strangulated hernia reduced 
"en masse" (Moullin.) 




Fig. 455. — Incomplete reduc- 
tion of strangulated loop. Hernia 
in a diverticulum. (Moullin-) 



tion persists (Fig. 454). This can occur in recent hernia in which 
the sac is not adherent and is most common in the direct form of 
inguinal hernia. 

It may be that instead of entering the peritoneal cavity the herni- 
ated loop has entered a diverticulum of the sac near the neck and 
there becomes once more strangulated (Fig. 455). 

It may be that the neck of the sac has torn loose from the rest of 
the sac and has been reduced with the gut, the strangulation still 
being maintained (Fig. 456). 

Again, a rent may be torn in the sac and the gut escaping there- 



HERNIOTOMY 



603 



B 



- C 



:rom pushes up between the peritoneum and the abdominal wall 
(Fig. 457). 

Finally the reduction may have been complete, but the gut was 
gangrenous or ruptured and a general peritonitis follows, due to the 
escape of the intestinal contents; or the peritonitis may even be 
due to the infection from the sep- 
tic fluids in the sac. 

Femoral and Umbilical Hernia. 
— These forms of strangulated 
hernia require the same modes 
of procedure as the inguinal but 
are likely to present more obsta- 
cles. In the case of femoral her- 
nia, if complete, the pressure 
must be made downward toward 
the saphenous opening at first, 
and then upward along the fe- 
moral canal. 

In the case of umbilical hernia 
the pressure must be made toward 
the umbilical ring. Often the 
Trendelenburg position is helpful. 
The constant effort is first to 
empty the gut and then reduce it. 

In both these forms of hernia 
the gut may be enveloped by a 
mass of omentum which may not 
be reducible and thus gives rise to 
some doubt whether the gut has 
been reduced. 

Operation for Strangulated Hernia : Inguinal Hernia. — To repeat, 
as soon as a hernia habitually reducible becomes painful and irre- 
ducible and is accompanied by the signs of beginning prostration, 
regard it as strangulated, and, aside from the exceptional cases 
indicated, operate at once. Do not wait for fecal vomiting for that is 
the last signal of exhausted nature — the precursor of death. 

General anesthesia is usually necessary, although in some cases of 




D 



Fig. 456. — Strangulated hernia reduced 
"en masse." A. Upper end of the loop. B. 
Neck of the sac torn off and reduced with 
the bowel. C. Reduced loop still strangu- 
lated. D. Scrotal portion of sac. (Lejars.) 



604 



STRANGULATED HERNIA 



profound sepsis local anesthesia with cocaine or stovaine suffices, 
using Schleich's formula and injecting the various layers just before 
dividing. No special instruments are necessary. 

Surgical Anatomy. — The special points to be remembered are the 
situation of the abdominal rings, the relations of the external and 
internal oblique and transversalis muscles to the inguinal canal, and 
the location of the deep epigastric artery. 

The external ring in the aponeurosis of the external oblique lies 
just above the spine of the pubes. The internal ring in the transver- 
salis fascia lies J£ i nc h above the 
middle of Poupart's ligament. The 
deep epigastric artery passing verti- 
cally between the two rings, lies be- 
tween the transversalis fascia and the 
peritoneum. 

The chief condition of operating 
well is to see and recognize what is to 
be divided. The coverings enumer- 
ated with such care by the text- 
books will not be distinguished, but 
there is little danger of cutting into 
the intestine, for before it can be 
reached the sac must be opened, and 
that is announced by the escape of a 
characteristic sero-sanguineous fluid. The greatest injury to the 
bowel is at the site of constriction, which may be at the external 
ring, the internal ring, or the neck of the sac. 

The preparation of the field of operation must be painstaking. The 
pelvis must be shaved and scrubbed; the adjacent abdominal and 
inguinal regions and the scrotum must be thoroughly disinfected; 
and the penis after cleansing wrapped in a sterile compress. 

First Step. Incision. Exposure of the Sac. — Begin with a skin in- 
cision extending from the internal ring down to the spine of the 
pubes; if it is a scrotal hernia, down to the middle third of the 
scrotum (Fig. 461). Go directly through the skin and layers of fat 
to the aponeurosis of the external oblique, dividing the branches of 
the superficial epigastric artery. 




Fig. 457. — Imperfect reduction by- 
taxis. Hernia outside the ruptured 
sac. (Moullin.) 



HERNIOTOMY 



605 



Expose the aponeurosis thoroughly and incise it from one ring 
to the other. It is easily recognized by the oblique direction of its 
fibers and its shiny look, and will serve during the operation as an 
important landmark. The lips of this wound should be caught up 
with forceps, especially at the external ring, to serve later as a guide 
in beginning repair. 

Once the aponeurosis is opened the sac is exposed and the next 
effort is to isolate it preparatory to its incision. Separate it from 




Fig. 458. — Strangulated inguinal hernia; primary incision. 



the aponeurosis by careful blunt dissection around its whole circum- 
ference and divide the remaining coverings layer by layer until the 
sac is exposed and identified. Strip these coverings by blunt dis- 
section, isolating the tumor up to the internal ring. 

If these layers are much adherent one may be in doubt as to 
whether it is the sac or the intestine which he has exposed. The 
nature of the blood supply will settle the question, for the vessels of 
the sac stand out distinctly, whereas those of the bowel are not 
distinguishable in the uniform congestion. 



606 STRANGULATED HERNIA 

Second Step. Opening the Sac. — Catch a fold of the sac with dis- 
secting forceps and cautiously divide the base of this fold with scis- 
sors or scalpel (Fig. 459). It may be one of the connective tissue 
coverings that is opened; divide it the full length of the wound and so 
proceed until finally the hernial sac itself is opened, which will be 
announced by a gush of bloody serum. Occasionally this serum will 
be lacking, the bowel being in intimate contact with the sac, or even 
adherent to it, but the bowel will be recognized by its uniform color- 
ing and will be separated as the opening in the sac is enlarged. 
Cautiously enlarge the opening till a finger can be introduced, and on 




Fig. 459. — Opening the sac of a strangulated hernia. As soon as the sac is opened a sero- 

sanguineous fluid escapes. (Guibe.) 



it as a guide, split the sac close up to its neck (Fig. 460). When the 
constricting band is reached slip the finger under it, if possible, and 
divide it completely. If too tight for the finger, pass a grooved 
director as a guide. In some cases it may be better to use a herni- 
otomy knife, but wherever possible avoid cutting blindly. The con- 
striction must be freely divided so that the intestine can be readily 
drawn down for inspection. This step is not complete till that is 
possible. 

It may happen that there is a second constricting band higher up; 
in such a case the forceps, which should always be attached to the 



HERNIOTOMY 



607 



lips of the incision in the sac, are useful in pulling it down so that 
what is to be divided can be seen. 

Third Step. Examination of the Intestine. — It is of the greatest 
importance that the site of the constriction be examined, for the chief 
lesions will be found there. Pull the gut down and observe the line 
of demarcation between the healthy and injured tissue (Fig. 461). 




Fig. 460. — Dividing the constricting fibers of the strangulated inguinal hernia. The parts 

should be well exposed. (Guibe.) 



One of the several conditions will be present and the line of procedure 
will depend upon the one which is found. 

1. The intestine is sound; that is to say, it has a uniform, dark 
violet color, most marked at the site of the constriction where it 
is lustrous. There is no erosion of the serous covering. Douching 
the bowel with warm normal salt solution restores its tonicity, its 
rounded outline, and after a few minutes it assumes a redder color 



6o8 



STRANGULATED HERNIA 



and is to be returned to the abdominal cavity. Following this the 
omentum which usually presents/is to be inspected. If there is a 
considerable mass or if its' vitality has been compromised it should 
be resected, using one or several ligatures as the case may require. 
Before the stump is dropped back into the peritoneal cavity it must 
be carefully inspected for bleeding points and should be sponged with 
salt solution. 

2. The intestine is slightly injured; that is to say, there may be 




Fig. 461. — Examination of the strangulated loop. (Veau.) 



several small zones of erosion exposing the muscular or even the 
mucous layer. Bury these areas with a few Lembert sutures, repair 
any injuries to the mesentery, and reduce. If the intestinal loop is 
long, a methodical procedure may be required to prevent further 
injury to tissues already compromised. The posterior segment of 
the loop should be reduced first, as it probably was the last to come 
down; in the meantime the anterior segment must be carefully sup- 
ported. The least rudeness may result in a tear. 



HERNIOTOMY 609 

3. The intestine is doubtful; that is to say, it has a color mottled 
gray and purple. It does not recover its form under the douching, 
but stays collapsed and flattened. Under these conditions it may 
not be possible to say whether it is gangrenous or not, but it should 
not be reduced. 

Treves, however, advises reduction under these circumstances, 
remarking (Operative Surgery, p. 534, Vol. II) that whatever theoret- 
ical objections to this procedure may exist, practice has shown that 
it may be safely carried out, assuming that this applies to a bowel 
which is not actually gangrenous, but in a condition which may be 
termed "doubtful." It is remarkable to what extent these doubtful 
intestines recover. The idea is that the peritoneal cavity is the 
most favorable site for recovery. 

If the operator is inexperienced and not certain that he can dis- 
tinguish between the bowel, possibly gangrenous, and that which has 
actually lost its viability, he must wait. Wrap the loop in moist 
gauze, and after twelve hours examine again. It may be gangrenous 
or it may be viable, lustrous, reddened, rounded, and impels the be- 
lief that it will become normal. With that belief, reduce it slowly 
and carefully, breaking up the slight adhesions which have already 
formed. 

4. The intestine is obviously gangrenous; that is to say, the serous 
coat has lost its luster, is blistered in spots, and can easily be stripped 
off with the fingers: its color is ashen or even black, sometimes 
mottled with white patches; there is a characteristic odor; the tissues 
are friable; and there may be perforations. 

In this case there is but one of two things to do: either anchor the 
gut in the wound and make an artificial anus, or resect the bowel. 

There can be no doubt that an enterectomy is the ideal procedure 
since it eliminates a source of danger and permits the radical cure 
of the hernia, but it is best not to undertake it unless skilled in intes- 
tinal suture (which for that matter every doctor should know thor- 
oughly how to do) for the time required may aggravate the shock 
and insure a fatality; but the first consideration is to save life. (See 
Enterectomy.) Allison, of Omaha (Jour. Minn. State Med. Assn., 
Jan., 1908), takes a different view: "We believe primary end-to-end 
anastomosis unjustifiable for, though we escape shock and peritonitis, 
' 39 



6lO STRANGULATED HERNIA 






there yet remains the danger of permanent obstruction due to circu- 
latory and septic changes, or a fatal paralysis due to distention and 
toxemia. Artificial anus offers the best way out. The two-stage 
operation is safer than the primary." 

If an artificial anus is considered safest, pull enough of the gut ou 
to reach sound tissue. Pass a catgut suture through the abdominal 
wall — that is, through the aponeurosis and the parietal peritoneum — 
and then through the superficial coats of the bowel, then out through 
the abdominal wall again to make the letter " U. " Employ four such 
sutures at the cardinal points. To the gangrenous loop apply a moist 
antiseptic dressing, changed hourly if the intestine was perforated. 
If the intestine was not perforated, do not open it at once, but wait 
a few hours till adhesions form. 

It is then to be opened and the dressings must be frequently 
changed, for the discharge will be abundant. Later the fistula may 
gradually close of its own accord, more and more of the bowel con^ 
tents passing by the rectum; or to cure the fistula a difficult operation 
may be necessary. (See Temporary Artificial Anus.) 

Fourth Step. Ligation and Amputation of the Sac. — In every case 
where the bowel may be returned to the peritoneal cavity, the treat- 
ment of the sac is of the greatest importance. After the intestine 
and omentum have been reduced proceed to disinfect and to dissect 
the sac, if this has not already been done, remembering that the 
structures of the cord may be very intimately connected with it and 
hard to separate. In the strangulated cases the sac is usually 
thick, but in the congenital cases it may be thin and friable. It is 
best to begin by separating the sac completely from the cord at one 
point, and then the dissection may proceed first toward the scrotum 
and then toward the peritoneum. In some cases it is best to make an 
incision through the whole circumference of the sac being careful 
not to divide the main vessels of the vas, the two portions being then 
dissected separately, carrying one down to the scrotum if necessary; 
the other, to the internal ring. Dry gauze dissection is the best 
method of separating these structures, as a rule. When the sac is 
completely isolated the neck is to be freed quite into the abdominal 
cavity, and then a finger is to be passed into the opening that any 
omental adhesions may be detected or any concealed hemorrhage. 



, 



HERNIOTOMY 



6ll 



Next, the sac is to be twisted and then ligated; or simple ligated as 
high up as possible, and amputated. 

In freeing the neck at the internal ring the subperitoneal fat is 
usually seen; at this stage the bladder may be injured, and the point 
is that any fatty tissues at the inner side of the ring must not be in- 
cluded in the ligature, for this fat may conceal the bladder. 

In ligating the sac it is best to transfix it rather than use the cir- 
ular ligature. If the sac has been split so high that the neck cannot 




Fig. 462. — Repair after relief of strangulated inguinal hernia. Suture of conjoined tendon 
to Poupart's ligament. C, Cord: E, epigastric artery; PO, internal oblique. (Guibe.) 



be defined, then the upper end of the peritoneal wound should be re- 
paired with a few stitches so as to reconstruct the neck which is then 
to be ligated. 

Fifth Step. — This will depend upon the condition of the patient. 
If his condition is serious, it is sufficient rapidly to reunite the apon- 
eurosis and repair the skin incision. If a little more time may be 
used, proceed to do the radical cure (Fig. 462). Unless this is done 



6l2 STRANGULATED HERNIA 

recurrence is almost certain, but the operator cannot be held respon- 
sible for that. In the urgent cases it is sufficient to have saved a life. 

Whether the radical operation is attempted or not, employ drain- 
age. The dressing must be carefully applied. 

Subsequent Treatment. — The patient must have no food for twenty- 
four hours. It may be necessary to employ salt solution freely. A 
little ice may be given to quench the thirst. At the end of twenty- 
four hours begin with small quantities of milk. Change the dress- 
ings the second day, or sooner if much soiled. On the third or fourth 
day give a laxative. Remove the drain on the fifth. Remove the 
sutures on the eighth or ninth. Peritonitis may supervene if the 
gangrenous areas have not been properly treated. 

POSSIBLE COMPLICATIONS IN THE OPERATION 

In the operation just described, the ordinary difficulties are indi- 
cated. But there are others, rarer, which may arise to disconcert the 
casual operator not forewarned. The actual operation is always 
easier if one has in mind all the possibilities. There may be unex- 
pected adhesions; there may be anomalies with resepct to the sac or 
its contents, or there may be unsuspected conditions produced by 
attempts at taxis. 

Adhesions must be anticipated when the hernia is large and has 
been for a long time irreducible, and under these circumstances 
special precautions must be taken not to wound the bowel in opening 
the sac. The adhesions if recent and soft may be broken up with the 
finger or grooved director keeping in close contact with the sac so 
as to avoid the bowel. 

If the adhesions are old and the union between the bowel or omen- 
tum with the sac firm and fibrous, it will be necessary to divide them 
with scalpel or scissors, but this is a procedure requiring patience 
and a delicate touch. If necessary, long, band-like adhesions may be 
divided between forceps and subsequently ligated. 

If, following the decortication, the raw surfaces ooze to any serious 
extent, apply hot, moist compresses for a moment, and either this 
will check the bleeding or at least reveal the site of ttolarger vessels 
to be caught up with forceps. Usually a few applications of the hot 



COMPLICATIONS IN HERNIOTOMY 613 

compresses will entirely suppress the oozing, or at least to such degree 
as not to contra-indicate reduction; for when the bowel is no longer 
bent and the circulation no longer interfered with the oozing will 
spontaneously cease. 

But it is chiefly injury to the bowel which is to be feared, not so 
much because the rent may be difficult to repair as that some of the 
septic contents of the bowel may escape. 

If the adhesions cannot be broken up the only thing left is to remove 
the source of the strangulation and leave the bowel outside. Occa- 
sionally it will be found that the source of strangulation is in some 
of the adhesions rather than the rings, or the neck of the sac; or, 
again, so much scar tissue in the bowel wall leaves it inert and para- 
lyzed. All these difficulties are more likely to occur in the neglected 
cases. 

A hernia of the cecum or sigmoid may present difficulties depend- 
ing upon adhesions. It must be remembered that these two portions 
of the large intestine are not completely invested by peritoneum; and, 
in consequence, it may come to pass that when they slide down 
through the inguinal canal a point is reached where a part of the bowel 
is outside the hernial sac, and this surface acquires adhesions to the 
scrotal tissues. In such cases these adhesions cannot be divided for 
fear of wounding important branches of the mesenteric arteries, so 
that to effect reduction a special procedure must be employed. 

In the first place, when, on opening the hernial sac, these parts 
of the large bowel are recognized, the neck of the hernia must be 
freely incised and the abdominal walls as well. In fact, one does 
I what Lejars calls a hernio-laparotomy. 

Next the hernial sac is separated from the spermatic cord and 
then an effort is made to reduce the hernia en masse, returning, if 
possible, the bowel and the peritoneal prolongation at the same time. 
It will be a slow and tedious process. It is greatly aided by the Tren- 
delenburg position. If the attempt fails, an artificial anus is the last 
resort. 

Among the anomalies of the sac which may bother the operator are 
diverticula and double compartments. One may open into what ap- 
pears to be the hernial sac and find it empty. In encysted hernia 
the processus vaginalis may be filled with fluid which surrounds the 



6 14 STRANGULATED HERNIA 

true hernial sac. A little study of the conditions will lead one to go 
ahead and find and open the true hernial sac. 

The hernial sac may push in between the peritoneum and the 
muscular layers, bulging toward the iliac fossa or the bladder. This 
is the pro-peritoneal hernia, and when it becomes strangulated it is not 
likely a diagnosis will be made. Yet the presence of a tumor in the 
inguinal region and the signs of intestinal obstruction will demand an 
operation and again a hernio-laparotomy is indicated. The site of 
strangulation is located and the bowel treated as in the ordinary 
form of strangulated hernia. 

In the interstitial form of hernia great difficulties may arise. The 
incision is likely to be quite different from the ordinary since it fol- 
lows the long axis of the tumor. Once the hernial sac is exposed it 
must be freed from its adhesions to the muscles. The neck of the sac 
corresponds to the internal ring, and if that is the site of constriction 
it must be divided by cutting outward. The deep epigastric artery 
lies to the inner side. 

After the bowel is reduced and the sac ligated, the break in the 
abdominal wall must be sutured, repairing the opening in each layer 
separately. 

The contents of the hernial sac may be abnormal. At some time 
or other each of the abdominal organs except the pancreas have been 
found herniated. It is the bladder which most often gives rise to 
trouble. 

It may be in the sac and appear as a second " sac " when the hernial 
sac is opened. It presents as a rounded, reddish tumor, perhaps as 
large as a hen's egg. Such a tumor should never be opened on sus- 
picion, but a careful effort must be made to locate its limits by blunt 
dissection. The fact that it leads down to, and behind, the pubes 
clears up any doubt. It is to be reduced in the same manner as the 
intestine. In other instances it is without the sac, lying to the inner 
side of its neck and is perhaps intimately connected thereto. It may 
be mistaken for a thickened portion of the sac or an adherent mass of 
fatty tissue. 

If it is opened into, the escape of urine and the evidence to the ex- 
amining finger of a large mucous-lined cavity reveals the nature of the 
accident and imposes immediate repair. 



APPENDIX IN HERNIOTOMY 6x5 

A large hernia, easily reducible, or one whose size diminishes, fol- 
lowing urination or the use of the catheter suggests hernia of the blad- 
der; but, unfortunately, these signs are not available in strangula- 
tion. In every herniotomy the danger of w r ounding the bladder must 
be kept in mind. 

Another point Lejars makes: One may expose a thin- walled trans- 
parent cyst at the inner side of the neck of the sac, and unwittingly 
open it only to find oneself working into the bladder. This trans- 
parent cyst, in nowise resembling the bladder, is due to a hernia of the 
mucosa of the bladder between the fibers of the muscularis. 

Following the separation of the bladder from the hernial sac the 
urine may be bloody for a day or two. This hematuria is of little 
moment and soon clears up. 

If the bladder is wounded its repair must precede everything else. 
As soon as the injury is discovered, pack around the site with sterile 
gauze, catch the edges of the wound with small forceps and suture, 
uniting the mucosa first with a continuous catgut suture, and the 
muscular coat with interrupted sutures, accurately applied; a third 
( line connects the superficial tissues. 

The appendix may be found in the hernial sac, either inflamed or 
normal. If the latter, it is to be removed in the ordinary way unless 
time presses, in which case one must be satisfied with reducing it. 

If the symptoms of strangulation arise in consequence of an in- 
flamed and herniated appendix, they may differ somewhat from those 
ordinarily observed. There will be the same tendency to collapse, the 
vomiting, the tympanites; but constipation may not be complete, and 
the hernial tumor, in addition to being swollen and painful, may be 
reddened and edematous. 

No one should think of taxis under these circumstances: as im- 
mediate operation is indicated. Regarding these grave cases, Kelly 
says (Vermiform Appendix and its Disease, page 793) where there is 
suppuration in the sac it must be drained, and here as well as in the 
cases where there is gangrene in the appendix, resulting from strangu- 
lation, the utmost care must be observed in handling the diseased 
tissues in order to avoid inoculating the peritoneal cavity. If the dis- 
eased portion is found to extend up into the peritoneal cavity, the 



6l6 STRANGULATED HERNIA 

operator must at all hazards discover the upper limits of the infection 
and resect the bowel in its healthy portion. 

Moreover, he must do this with the least possible manipulation 
and traction upon the parts, preferably by enlarging the abdominal 
opening in the direction of the inguinal canal while protecting the 
healthy regions and keeping the disease well isolated by abundant 
gauze compresses. 

When infection extends still further up into the abdomen an even 
wider incision must be made, if necessary, in the form of an inverted 
X in order to provide abundant drainage after removal of the disease. 
In such cases the cure of the hernia becomes a matter of secondary 
consideration to be taken up after recovery. 

In a case seen by the author the patient was an old woman, for 
years affected with an inguinal hernia usually easily reduced. It 
became strangulated, presenting a hard painful, inflamed lump, 
the size of a hen's egg. 

She was nauseated, in much pain, slightly febrile, only slightly 
tympanitic, and enemas were effective in moving the bowel. The 
operation revealed a strangulated appendix and nothing more. It 
was well exposed and resected without difficulty and with complete 
relief. In repairing the abdominal wall the sutures were passed 
through the lower edge of the external oblique, through Poupart's 
ligament and out through the upper edge of the aponeurosis, com- 
pletely obliterating the inguinal canal. This combination is unusual 
— an old woman, an inguinal hernia and a strangulated appendix. 

McEwen (London Lancet, June 16, 1906) reports a case in which 
the patient, a man of sixty-two, presented himself for an opera- 
tion for strangulated hernia. Two weeks previously his hernia (of 
twelve years' standing) had begun to give him pain, which had gradu- 
ally increased. 

A large pyriform tumor occupied the right inguinal region and 
the scrotum, which was much inflamed. The mass was dull on per- 
cussion, there was no impulse on coughing, and it was irreducible. 
On opening the sac the hernia was found to consist of the appendix, 
held in position by a pin protruding through its wall. There was no 
abscess formation, yet it was not deemed advisable after removal of 
the appendix to proceed with the radical cure. 



FEMORAL HERNIA 617 

Regarding these unusual conditions, Lejars remarks that in be- 
ginning an operation for strangulated hernia we should expect every- 
thing and be surprised at nothing; laying aside for the moment all 
theoretical discussions and applying ourselves to the chief indication, 
not deeming our work complete until the bowel is properly reduced 
and lost to view in the abdominal cavity. 

Oliver, of Indianapolis (Ind. Med. Jour., March, 1908), reports a 
case in which the hernia had grown to remarkable proportions ex- 
tending as low as the knee. The mass had long been irreducible. 
The patient was a butcher of about fifty years of age. Following a 
heavy meal of " pigs' feet" and a lift, his hernia suddenly became 
painful and he experienced the sensation of something giving way; 
symptoms of strangulation in mild form gradually developed; taxis 
being out of the question, immediate operation was practised. On 
opening the hernial sac it developed that its content was the stomach 
in its entirety, but no gut was present. With great difficulty it was 
reduced. The patient's condition did not permit of any further 
manipulation, and shortly afterward he succumbed. Oliver ex- 
presses the opinion that the stomach had been forced down into the 

- - --"■■it 
sac by the strain, replacing the gut. 1 

Strangulated Femoral Hernia 

Operation is even more urgent in the case of strangulated 
femoral hernia than in strangulated inguinal hernia. Gangrene 
is likely to develop earlier, and taxis is all the more ineffectual by 
reason of the anatomical arrangement. Especially must one be 
on his guard in the case of small hernia for the ring is unyielding. 
It is essential to have the anatomy in mind to understand this and 
especially in order to operate without embarrassment. 

Surgical Anatomy. — Poupart's ligament stretches across the front 
of the pelvic region from the anterior superior spine of the ilium to 
the spine of the os pubis. The space between this band and the 
ramus of the pubis is occupied by several structures — from without 
inward, the iliacus and psoas muscles on their way to the lesser 
trochanter, the crural nerve, the femoral artery and vein, the femoral 
canal, and Gimbernat's ligament. 



6i8 



STRANGULATED HERNIA 






Gimbernat's ligament is a firm triangular fascia with its base 
directed outward and abutting the femoral canal. 

The femoral sheath, a prolongation of the iliac fascia, encloses the 
femoral vessels. In the thigh it fits closely about the vessels. 







Fig. 463. — Relations of the neck of a femoral hernia under Poupart's ligament. Beneath 
Poupart's ligament from without inward; the iliacus, the psoas, the femoral artery, the vein, 
the hernia, concealing Gimbernat's ligament which is between its neck and the pubes. 
(Moullin.) 

In the groin the sheath is more capacious so that there is a space 
left between its inner wall and the femoral vein. This space consti- 
tutes the femoral canal. The femoral canal is, therefore, conical in 
shape with its base above and its apex below where the sheath gets 
in contact with the femoral vein. The circumference of the base 



HERNIOTOMY. FEMORAL HERNIA 619 

constitutes the femoral ring which is bounded internally by the base 
of Gimbernat's ligament; above, by Poupart's ligament; below, by 
the ramus of the pubes; externally, by the femoral vein. The narrow 
orifice bounded by these structures is the usual site of strangulation 
of a hernia descending along this slender channel. 

It is Gimbernat's ligament whose sharp edge is most likely to 
shut off the circulation of a loop of intestine bulging past it and which 
is most likely to cut into or bruise the bowel in efforts at taxis (Fig. 

463)- 

In other cases the hernia descending lower finds the direction 
of least resistance toward the surface and bulges out through the 
saphenous opening and the cribriform fascia. 

Operation. — If the operation is done early before complications, 
such as gangrene, have arisen, the operation for strangulated femoral 
hernia is simple and without special danger. Begin by disinfecting 
the whole field; the inner surface of the thigh, the groin, the abdomen, 
the genitals, 

The incision may be vertical following »the axis of the tumor, or 
oblique, below and parallel to Poupart's ligament; Lejars prefers the 
latter, claiming that it gives freer access to the femoral ring, facili- 
tates the dissection of the sac and the procedures in the radical cure. 

The vertical incision is probably better for large and lobulated 
hernia which extend well below Poupart's ligament. But whatever 
incision is employed must be of ample length. 

The incision traverses the skin, and then a fatty layer through 
which ramify a number of veins tributary to the long saphenous. 
Having divided this layer, the sac is exposed; or, at least, the fatty 
envelope in which so often it is enclosed — a collection of fat which 
at times amounts to a veritable lipoma. The hernial sac lies im- 
mediately beneath this fat — sometimes in thin subjects immediately 
beneath the skin — and presents itself in divers aspects. Usually 
it looks like a tense and reddish cyst; often it is lobulated 
(Fig. 464). 

Second Step. — Isolate the sac. Proceed to separate it from the 
adjacent tissues by blunt dissection, peeling it out with the fingers, 
and disengaging it quite up to the neck. It is essential for the later 



620 



STRANGULATED HERNIA 



steps of the operation that this be thoroughly done and is complete 
when Poupart's and Gimbernat's ligaments are well in view. 

This dissection of the sac takes less time than one might expect 
and is greatly facilitated if one is able to find a line of cleavage be- 
tween the tissues. Sometimes bursae intervene between the sac 
and adjacent tissues and favor a rapid separation. 

Third Step, — Open the sac; examine the contents. Once the hernial 
tumor is well exposed up to the constricting ring, cautiously incise 
the sac. Caution is required because often it is difficult to know 
when one has penetrated the sac and an adherent intestine may be 



..:#¥/, 




Fig. 464. — Strangulated femoral hernia: primary incision exposing hernia and Poupart' 

ligament. (Guibe.) 



wounded. In this form of hernia the true sac may be covered by 
a cyst, which may be filled by bloody serum and thus simulate the 
appearances of the hernial sac. A moment's examination, however, 
shows that it is a small closed cavity without communication with 
the abdomen. The layers are to be cautiously divided one by one 
until the sac is opened into and the opening enlarged. 

Catch up the lips of the wound of the sac and examine its contents. 
Usually, in this form of strangulated hernia, one will see a small loop 
of intestine, darkened, tense, and tightly constricted. Occasionally 
along with the omentum there may be several loops of small intes- 
tine, or the cecum, or the sigmoid flexure. Irrigate the cavity and 



HERNIOTOMY. FEMORAL HERNIA 



621 



its contents with normal salt solution and prepare to relieve the 
constriction. 

Fourth Step. — Relieve the constriction. The first effort should be to 
relieve the strangulation by stretching the offending fibers, to this 
end introducing a finger, if possible, into the ring along the inner side 
of the hernia. 

Oftentimes the pressure thus exerted will, with a little effort, 
stretch and enlarge the opening sufficiently to relieve the constriction 
and to permit the necessary manipulation of the bowel. 

It may not be possible to introduce a finger, and then one must 
resort to incision. To accomplish this a grooved director may be 




Fig. 465. — Strangulated femoral hernia: closing the femoral canal. Note manner in which 
sutures are passed, avoiding femoral vein at outer border. 

slipped up alongside the bowel and the fibers divided with scissors or 
bistoury; or if the fibers are in plain view, as they should be, they may 
be nicked with the point of the bistoury and when room is thus made 
the finger may be introduced as before. The use of the herniotomy 
knife should be reserved for exceptional cases, where the subject is 
fleshy and the obstruction beyond reach and very tight. 

But whatever method may be practised, one must keep to the 
inside, cutting inward or upward to avoid injury to the bowel or the 
femoral vein. 



62 2 STRANGULATED HERNIA 

When the obstruction is removed pull the bowel down and ex- 
amine it. If it is suspicious or gangrenous, treat it after the manner 
indicated under Strangulated Inguinal Hernia. 

If it is sound, reduce it; liberate the sac around the femoral ring, 
ligate and resect it; and close the femoral canal. The after-treatment 
is the same as for inguinal hernia. 

Fifth Step. — Close the femoral ring. Two circular sutures acting 
when tied after the manner of a purse string are to be passed: 
one including the pectineal fascia and the fascia of the external 
oblique; the second, more deeply placed, including the pectineal 
fascia, Poupart's ligament and Gimbernat's ligament. 

Avoid wounding the femoral vein, which lies in contact with the 
outer border of the femoral ring. When these sutures are tied the 
external oblique is pulled down into close contact with the pec- 
tineal fascia and the canal obliterated (Fig. 465). 

It remains to be said that in exceptional cases it may be necessary, 
in order to see what to do, to divide Poupart's ligament; or, in the 
male where the cord is to be avoided, to make another incision along 
the inguinal canal, exposing the neck of the hernia; or, following the 
method of Tuffier, to open directly into the peritoneal cavity through 
the inguinal canal. 

Strangulated Umbilical Hernia 

A strangulated umbilical hernia is peculiar in two or three respects. 
It is likely to be deceptive in that the characteristic symptoms of in- 
testinal obstruction may be wanting. The site of strangulation is 
more likely to be in the sac than at the umbilical ring. But because 
the absolute signs of obstruction are absent and because the opening 
at the umbilicus seems patent, one has no excuse to delay when an old 
and long irreducible rupture becomes suddenly painful, with vomiting 
and partial constipation. 

Too often, as Lejars says, we call these attacks with comparatively 
mild onset, pseudo-strangulation; and so the case drifts along while 
septic absorption goes on insidiously but surely. From day to day 
the circulation grows weaker, the abdomen more tympanitic, the 
vomiting more pronounced, until the vital forces are practically over- 



STRANGULATED UMBILICAL HERNIA 



623 



come, at which time, too late, it is decided to operate. The expect- 
ant treatment and repeated taxis in these cases are merely methods 
of "losing time." 

Following such practice one can confidently expect a large per- 
centage of fatalities, though one should not hesitate to operate even 
in the face of such odds. Operating early, one may give assurance of 
excellent results. To quote Lejars again, it is not the operation 
which is to be feared: it is the delay. 

Operation. — Careful disinfection of the whole abdominal wall; a 
prudent and cautious anesthesia. The incision may follow the 




Fig. 466* — Strangulated umbilical hernia: incision skirting the base of the tumor. 
The peritoneum opened in the same line exposes the omentum and bowel. Omentum 
clamped and divided along dotted line. (Guibe.) 



median line extending well beyond the tumor above and below (Fig. 
466); or in the case of a large tumor, may consist of two semilunar 
incisions on either side of the middle line which enables one to get rid 
of redundant tissue. 

In either case the incision must not go deep from the first for 
often the skin is quite thin, often adherent to the sac, and it is easy 
to go directly into the sac. By reason of this adhesion at the center 



624 STRANGULATED HERNIA 

of the tumor, begin the dissection at the poles of the incision and 
work toward the center. 

As soon as the skin is detached proceed to isolate the tumor, if 
possible, up to its point of emergence. It may not be practicable 
if the tumor is large and lobulated to take the time, and in such a 
case the sac may be opened into at once. 

Second Step. — Open the sac. Detach the omentum. Nearly always 
on first opening the sac only omentum can be seen. It completely 
envelops the bowel. The fingers are gently insinuated between 







Fig. 467. — Strangulated umbilical hernia: the sac^laid open to relieve the strangulation 

and free the bowel. (Guibe.) 

the omentum and the sac, and the adhesions progressively broked 
down. Wherever a lobule of omentum is found encysted in a diver- 
ticulum of the sac, it must be dissected out in the s^me manner. 
Finally the entire omentum will be freed, may be lifted up, and the 
gut exposed. In other cases divide the omentum as indicated in 
Fig. 489. 

Irrigate both the bowel and omentum with normal salt solution, 
wipe with sterile gauze and examine the bowel carefully to see that 
there is no danger of perforation and of soiling of the peritoneum in 
the process of reduction. 



STRANGULATED UMBILICAL HERNIA 



625 



Third Step. — Relieve the strangulation. Oftentimes the umbilical 
ring may need only to be stretched a little to permit the free manipu- 
lation of the bowel; again, it may be necessary to divide the con- 
stricting fibers. This may be most readily accomplished by pulling 
down the omentum, slipping a ringer between it and the upper part 
of the ring to the left of the middle line. If this nick does not give 
sufficient release, repeat on the opposite side. 




Fig. 468. — Strangulated umbilical hernia: completing section of base of the tumor. (Guibe.) 



When the necessary room is obtained, ligate the omentum, resect 
it, cleanse the stump and reduce it that there may be nothing to 
interfere with the treatment of the bowel. If the omentum has been 
resected in the manner indicated, the tumor mass may be laid wide 
open in order that the strangulated loops may be well exposed and 
freed (Fig. 467). 

Following this the incision is continued around the base of the 
tumor, completely removing it and leaving the various layers of 
the abdominal wall exposed ready for repair (Fig. 468). 

With respect to the bowel, the same principle of treatment holds 
good as in inguinal hernia. Repair any slight defects or abrasions. 
40 



626 



STRANGULATED HERNIA 



If its viability is doubtful, keep it under observation for a few hours. 
If gangrenous, either anchor it in the wound and make an artificial 
anus or do an enterectomy. 

It may be that in very large umbilical hernia it is better to modify 
the procedure, following the plan of Mayo and others, in order to 
gain time. 

A transverse elliptical incision is made around the tumor at such 
distance from the center that the redundant tissue shall be removed. 
Cut down to the sac. Next cautiously open the sac following the 
skin incision. Apply several forceps to the edges of the sac so that it 







Fig. 469. — Peritoneum closed and first layer of mattress sutures for fascia passed. (Guibe.) 



is constantly under control. Detach the omentum, freeing it com- 
pletely up to the neck of the sac. Ligate and resect it, and working 
along its under surface free it from the bowel. Once detached the 
paquet of omentum carries with it a segment of the skin and of the 
sac. 

The bowel is next treated and reduced. This may not be as easily 
done as said, for there are several circumstances under which the 



STRANGULATED UMBILICAL HERNIA 627 

bowel may push out and threaten eventration. But no effort should 
be made to push back the rebellious loops en masse. 

Proceed at once to enlarge the opening, lift up the edges of the 
peritoneum by the attached forceps and cover the bowel with a wide 
compress, tucking its edges under the belly walls on all sides, as de- 
scribed elsewhere. As little by little the bowel is returned the edges 
of the compress are slipped farther under. When reduction is com- 
plete the compress is left in situ until the sutures are placed. 



Fig. 470. — Second layer of mattress sutures completing the overlapping of 

the fascia. (Guibe.) 

Fourth Step. — The mode of repairing the abdominal wall varies 
with the circumstances and the operator, and depends upon how 
much time one may take. When the condition of the patient 
imposes great haste it must suffice to pass interrupted sutures 
through the whole thickness of the belly wall and draw the edge of 
the wound together so that the peritoneal edges point out and the 
two serous surfaces are thus brought into contact. Before the last 
suture is tied the compress is removed; and finally a continuous su- 
ture will complete the reunion. 

If more time is available, the sac is trimmed down to the perito- 
neum proper and its edges sutured as after a laparotomy. The 
sheaths of the recti muscles are opened up and the inner border of each 
muscle exposed. The two sides are then brought in contact and three 



628 



STRANGULATED HERNIA 



tiers of sutures applied; one uniting the deep layer of the rectal sheath 
to its fellow of the opposite side; the second uniting the two muscles; 
the third uniting the two superficial layers of the sheath overlapping 
and securing them by mattress sutures (Figs. 469 and 470). 




Fig. 471. — Umbilical hernia: dissection of sac. (Mayo.) 

Finally the excess of subcutaneous fat is trimmed away and the 
skin sutured. The usual dressing is applied, held in place by a wide 
binder, and the after-treatment, already indicated, is instituted. 

Figs. 471 and 472 show the manner in which Mayo perfects the 
radical cure. 

Obturator Hernia. — A strangulated obturator hernia is rare, yet 
it is to be thought of and ruled out before opening the abdomen for 



STRANGULATED OBTURATOR HERNIA 



629 



intestinal obstruction. Several points help to locate the trouble 
even when no marked tumor is present. The presence of pain over 
the region of the obturator foramen directs the attention to that 
point, and pressure made there projects a pain down the inner side 




Fig. 472. — Umbilical hernia: repair of abdominal wall. (Mayo.) 



of the thigh to the knee, along the course of the obturator nerve. In 
the female, vaginal examination will reveal the tumor. 

In this form of strangulated hernia, taxis is useless and likely to be 
very harmful, and therefore must never be employed. A herniotomy 
must be done without delay, though in these cases it is a procedure 



630 



STRANGULATED HERNIA 



by no means simple. Several anatomical points must be borne in 
mind. The hernia usually comes out through the upper part of the 
obturator membrane and is covered over by the pectineus muscle. 
It may work into the pectineus or it may lie on a lower level, working 
into the obturator externus. The pectineus is usually the chief 
guide to the hernia. 









m 




Fig. 473. — Obturator hernia. A, Hernial sac-obturator artery; B, pectineus; C, ad- 
ductor longus. (Lejars.) 



The obturator vessels and nerve are usually found behind and to 
the outer side of the neck of the hernia. The femoral vessels lie 
to the outer side. It is the obturator membrane which constitutes 
the constricting ring. 

The operation, chiefly as described by Treves, is as follows: The 
pelvis is elevated, the thigh flexed and adducted, the femoral artery 
located, and about a finger's breadth internal, an incision is made from 



STRANGULATED UMBILICAL HERNIA 63 1 

the spine of the pubes downward for 3 or 4 inches. Incise the 
skin, the subcutaneous fat and the fascia lata, and expose the adduc- 
tor longus. Catch up the deep external pudic artery. Retract the 
adductor brevis and beneath this is the pectineus w T hose fibers are 
separated by blunt dissection; or, if necessary, divided in order to 
expose the sac (Fig. 473). 

When the sac is once in view, free it completely up to the neck. 
The obturator membrane is now to be nicked, observing first the 
course of the arteries. It may be better, however, to open the sac 
at once, cleanse the contents, and endeavor to insinuate the finger 
alongside the bowel and stretch the strangulating fibers; failing in 
this, to divide them, keeping in mind the possibility of a hemorrhage. 
If, in spite of precaution, this occurs, tampon firmly against the 
obturator membrane, and w T hen the tampons are removed one by one, 
the bleeding points may be recognized and clamped. Finally the 
intestine, if sound, is reduced, the sac dissected and ligated high up, 
and the external wound sutured. 

Lejars remarks that one may find in the sac of a strangulated 
obturator hernia not only bowel and omentum, but also the tubes 
and ovaries, the bladder and the appendix; and that it is well to 
be forewarned of these possibilities, which may greatly complicate 
an operation at best never simple. 

Of strangulation of other forms of hernia — sciatic, lumbar, perineal, 
vaginal — it need only be said that they are too rare to be with profit 
considered here. 



CHAPTER XII 



RADICAL CURE OF INGUINAL HERNIA 



5.0 POT.KtP 



The radical cure of hernia may be attempted at the operation for 
strangulated hernia under the conditions defined. But aside from 
those emergency cases there are others in which the family doctor 

will feel it his duty to recommend and to do 
the operation. His results will be excellent if 
he wisely chooses cases not beyond his skill. 
As Veau says, he should select only such as 
are small, reducible, congenital. The large 
hernias are difficult to handle and recurrence 
will be almost certain. The irreducible hernias 
may have acquired adhesions that can scarcely 
be broken up without severe injury to the gut. 
With respect to age, the ideal case is a young 
man fifteen to twenty-five years old, who has 
well-developed abdominal walls, a well-defined 
external abdominal ring, and a hernia easily con- 

Fig. 474.— Transverse trolled by a trUSS. 
vertical section of the X ti i r 11 v.* ,11 

inguinal canal showing Under these favorable conditions, the hernia 

relation of the hernial ra rely recurs; but almost certainly it will recur 

Hque; p'o, Vernal ob- if suppuration follows the operation, and there- 

lique; t, transversaiis; f ore absolute asepsis is the sine qua non of 

Ft, transversaiis fascia; 

P, peritoneum; TC, con- SUCCeSS. 

joined tendon; Crem., Surgical Anatomy. — The hernia, then, which 

cremaster; cd, vas det- , , . . , , , , . 

erens in contact with the general practitioner should undertake to 
the hernial sac repre- operate on is an external or oblique, which 

sented in black. {Veau.) . , , , . , . - , , 

escapes from the abdominal cavity through the 
internal ring to the outside of the deep epigastric artery and follows 
the inguinal canal down to the external ring (Fig. 474). 

Beneath the skin will be found only a few insignificant vessels. 

632 




SURGICAL ANATOMY 



633 



The aponeurosis of the external oblique is easily distinguished, 
strong and resistant, and its fibers bounding the external ring are 
thickened to form the "pillars" of the ring. Behind it lies the cord, 
which includes the vas deferens and its accompanying vessels and 
nerves, all surrounded by a common sheath derived from the trans- 
versalis fascia, and in this case, it contains also the hernial sac. To 
reach the sac, the sheath must be divided and the elements of the 
cord separated from the sac. 





m 



/, 

5£ --; :',n 



Fig. 475. — The primary incision for hernia. (Veau.) 

In the case of congenital inguinal hernia, the sac is very thin and, 
in spite of precautions, it is sometimes torn or one even fails to find 
it. The chief difficulty of the operation centers around the recogni- 
tion and dissection of the sac. The posterior wall of the inguinal 
canal is formed by the conjoined tendon, the transversalis fascia, and 
the peritoneum. 

The purpose of the operation is to reconstruct the posterior wall 
and restore the obliquity of the canal, and the "Bassini" operation 
is the type the inexperienced operator can best imitate. 

Operation. — Prepare the field most scrupulously — abdomen, 
thigh, and scrotum. Employ general anesthesia, as a rule, al- 
though local and spinal anesthesia are available. 



634 



RADICAL CURE OF INGUINAL HERNIA 



Begin by locating the external ring, which is to be the first point 
of attack. 

The incision will extend from this orifice to a point just over the 
internal ring, which lies % inch above the middle of Poupart's 
ligament. The incision, then, beginning above (on the right), ex- 
tends downward and forward to the spine of the pubes, where it 
bends a little to become more vertical and ends in the base of the 







Fig. 476. — The external oblique exposed and the external ring developed. (Veau.) 

scrotum (Fig. 475). However large the hernia may be, one need not 
extend the incision further, so lax and distensible are the scrotal 
tissues. 

Having divided the skin and subcutaneous tissues, catch up and 
ligate the small vessels. Next divide the fatty tissues layer by 
layer down to the aponeurosis of the external oblique, which lies 
deeper than one may expect. 

Now, with the grooved director, completely expose the pillars of 
the ring. Do not neglect this as it is a most important step in the 
operation. The inner pillar is easily found, but the outer pillar is 
covered by the cord and a little patience is required to get it well 
exposed. Catch up each pillar with forceps; these are not to be 



DISSECTING THE SAC 635 

loosened until, at the end of the operation, they have served as a 
guide in the repair of the external ring (Fig. 476). 

Now comes the next step in the operation. Carefully divide the 
aponeurosis in the line of the pillars and to the full extent of the skin 
wound. Unless one cuts deeply, there is nothing to fear. You have 
now laid open the inguinal canal and have left to do the most diffi- 
cult part of the operation. 




Fig. 477. — The external oblique divided, exposing the cord and hernial sac. (Veau.) 

To Find and to Dissect Out the Sac. — The cord is covered by the 
cremaster which also covers the hernial sac. You may begin the 
search for the hernial sac without disturbing the position of the cord, 
but it is better to raise it up out of its bed. To do this follow along 
the external pillar and Poupart's ligament and you will find it easily 
disengaged by blunt dissection (Fig. 477). Slip the left index finger 
under and support the cord. The sac is enclosed in the fibrous 
sheath of the cord. 

Very gently incise this sheath, using a sharp bistoury (Fig. 478), 
and the structures of the cord appear. Rolling them between the 
finger and thumb, youxan recognize the vas deferens by its form and 
consistency. You can see the distended veins. You will see a 
whitish transparent membrane. Catch up a fold of it with the for- 
ceps and divide its base, and if it is the sac, you will open into a serous 
cavity (Fig. 479). Enlarge the orifice sufficiently to introduce a 
finger and, with that as a guide, dissect the sac from its associated 



6 3 6 



RADICAL CURE OF INGUINAL HERNIA 




Fig 478. — Dividing the fibrous coverings of the sac. (Veau.) 




Fig. 479.— Incising the hernial sac. (Veau.) 



DISSECTING THE SAC 



637 



structures (Fig. 480). It is often a difficult task, for the veins and 
vas deferens are glued to the sac, especially in the congenital hernia. 
Sometimes pressing and stripping the tissues back with a gauze 
compress facilitates the maneuver. Still there need be no great 
difficulty if only all the coverings are divided with the scalpel or 
scissors, exposing a plane of cleavage. Pulling and tearing and 
lacerating the tissues in the effort to liberate the sac, provokes 
a capillary oozing and predisposes to infection. 




Fig. 480. — The index finger introduced into the sac which is being separated from the other 

structures of the cord. (Guibe.) 

It is important that the sac be isolated quite to the internal ring 
(Fig. 481) ; otherwise when the ligature is applied there will be formed 
a peritoneal diverticulum, the starting-point later of another hernia. 
Do not carry the dissection further than the internal ring for fear of 
wounding the bladder. 

Assure yourself now that the sac is empty by passing a finger up 
into the abdominal cavity. Now transfix the neck of the sac with a 



6 3 8 



RADICAL CURE OF INGUINAL HERNIA 




Fig. 481. — The sac separated from the cord; the cord in the bottom of the wound; on 
either side are the lips of the external oblique, the forceps still attached to the pillars of the 
external ring. (Veau.) / 




Fig. 482.^-Ligation of the neck of the sac. (Veau.) 



ABDOMINAL REPAIR 



639 



needle carrying a catgut ligature (Fig. 482) and tie in the manner in- 
dicated in figure (Fig. 483). If the ligature merely encircles the 
neck, it is too likely to slip off. Do not cut off the ends of the liga- 
ture until through dealing with the sack. Amputate the sac within 
}/2 inch of the ligature and, if everything is all right, cut the 
threads and the stump disappears in the cavity. Sellenings proposes 
to dispense with the dissection of the sac. After it is exposed, in- 
cised, and emptied, he obliterates it by passing a purse string around 
its neck at the internal ring and suturing the rest of its length (Amer. 
Jour. Surgery, March, 1909). 






Fig. 483. — Illustrating method of ligating 
the sac. (Veau.) 



Fig. 484. — The cord drawn to one side 
while the posterior wall of the canal is 
restored by suture of the conjoined tendon 
to the shelving edge of Poupart's ligament. 
(Veau.) 



Suture of the Abdominal Walls. — This is the next step. Draw the 
cord down out of the way for the moment and expose the shelving 
inner edge of Poupart's ligament, which is to be sutured to the free 
border of the conjoined tendon. In other words, the internal oblique 
and transversalis are to be sutured jointly to Poupart's ligament. 

Through this shelving edge near the pubis pass a chromic catgut 
suture on a curved needle and carry it through the corresponding 
part of the conjoined tendon (Fig. 484), and apply three or four such 
sutures (Fig. 485). In this manner reconstruct the posterior wall of 



640 



RADICAL CURE OF INGUINAL HERNIA 



Complete the hemostasis. 



the inguinal canal. Place the cord back in position upon this line o 
sutures. 

Now draw the edges of the divided aponeurosis into position by 
means of the forceps attached to the pillars at the beginning of the 
operation. Begin the repair by a chromic catgut suture at the upper 
end of the wound (Fig. 486) and pass six or eight in this manner. 
The last will rejoin the pillars and restore the external ring, and 
when these are all tied the anterior wall of the canal is thus recon- 
structed. There is some danger of making the external ring too 
small for the cord (Fig. 487), with the result finally that the testicle 
atrophies. 

A scrotal hematoma may develop 
unless one is very particular about 
the oozing. 

Complete the operation by suture 
of the skin wound with silk-worm- 
gut, leaving in it a small drainage- 
tube if you fear infection or oozing; 
otherwise this is not necessary; still 
it does no harm. 

The dressing is of extreme im- 
portance. Cover the wound with a 
strip of moist gauze, fix it with collo- 
dion, and then apply the ordinary 
gauze and cotton dressing. A double spica bandage will greatly 
diminish the chance of infection. If drainage was employed, remove 
the tube in two or three days under strictest asepsis. Otherwise do 
not disturb the dressing, but watch the temperature. If the tem- 
perature runs up to 101 on the third day, open up the wound by 
removing one or two sutures, and if there is any pus, drain. 

Delay in this is likely to result in extensive suppuration, and a 
recurrence of the hernia is thus assured. If everything goes well, 
remove the stitches on the eighth day, but keep the patient in bed 
for three weeks. A truss is not necessary. 

Rilus Eastman, of Indianapolis, recommends a modification of the 
final suturing especially applicable in the case of children. His 
method aims at the closure of all the layers by a single tier of easily 



■ 




Fig. 485.- 



-Posterior wall-repair com- 
plete. (Veau.) 



ABDOMINAL REPAIR 



641 



removable non-buried sutures. The method described (Annals of 
Surgery, Jan., 1906) consists in the reduction of the sac by the ordi- 
nary procedure. A Pagenstecher celloidin linen suture bearing a 
needle on each end is then first passed through Poupart's ligament 




Fig. 486.- 



•Reconstructing the anterior wall by repair of the external oblique, 
still attached indicate the position of the ring. (Veau.) 



Forceps 



from without inward 1 inch from its free margin. It is next 
passed through the outer border of the obliquus externus and trans- 
versalis muscles and brought back through Poupart's ligament 
about 1/3 inch nearer the margin than at its first point of passage. 




Fig. 487. — External oblique repaired. (Veau.) 



The needle now external to, and above Poupart's ligament is made to 
J overlap the free margin of the ligament and the aponeurosis of the 

external oblique by carrying the thread through in the form of a 
I simple running mattress suture. 
I 4i 



642 



RADICAL CURE OF INGUINAL HERNIA 



The needle is next passed through the superficial fascia, panniculu 
adiposus, and skin, emerging about 1/8 inch from the skin wound 
margin upon the side opposite Poupart's ligament. When traction 
is made upon the two ends of the suture no kinks or curls remain, 
and the suture is tied up as a simple loop. Five or six such sutures 
are required to coapt the wound from the internal ring to the pubes. 
When union is complete they are easily clipped and removed. 



, 






CHAPTER XIII 
RADICAL CURE OF FEMORAL HERNIA 

Aside from the cases of strangulated hernia, the general practi- 
tioner should not undertake the operation for the radical cure of 
femoral hernia without due consideration and without warning the 
patient that relapse is possible and even frequent. The operation 
is not more difficult than that for inguinal hernia, but a cure is much 
less certain. As with inguinal hernia, he should select only such 
cases as are small and reducible. 

Surgical Anatomy.— The sac of a femoral hernia is generally thick 
and imbedded in adipose tissue originating in the extra-peritoneal 
layer. (See Strangulated Femoral Hernia.) 

The relations at the neck are of the greatest importance. To the 
outside is the femoral vein in direct contact, easily perforated by a 
careless needle and producing a hemorrhage that can be arrested 
only by ligature of the vein. To the inside is Gimbernat's ligament, 
sharp-edged and tense, the chief structure to be dealt with in strangu- 
lation. Above is Poupart's ligament, separating the femoral from 
the inguinal canal, and below is the ramus of the pubes, thinly cov- 
ered by the pectineus and its fascia. These boundaries are unaccom- 
i modating structures in the matter of repair, and for this reason 
relapse is frequent. 

Operation. — The anesthesia and preparation are the same as for 
■ inguinal hernia. 

The incision, parallel with, and a finger's breadth below Poupart's 
ligament, begins (on the left side) at the spine of the pubis and is 
usually about four inches in length (Fig. 488). 

Incise in the same manner the fatty tissues, layer by layer, until 
the easily distinguishable coverings of the hernia are reached. The 
line of cleavage between them and the fatty tissues is followed and 
the neck, lying high and deep, is exposed. Poupart's ligament is 

643 



644 RADICAL CURE OF FEMORAL HERNIA 

next freely exposed. Where coverings seem thinnest, catch up a 
fold with the dissecting forceps and incise the base. It may be that 
the incision will only open into another fatty layer. Divide the next 
layer in the same manner, and so proceed until you have opened 
the sac; secure its edges with forceps and pass an index finger into 
the cavity. If omentum is found it must be resected (Fig. 489). 
Be sure there is no adherent bowel. 



%:, 




Fig. 488. — Incision for femoral hernia. (Veau.) 

Now dissect the sac, proceeding slowly and methodically until the 
femoral ring is reached. Introduce a finger to be sure the bowel is 
protected, and transfix and ligate the neck of the sac as in inguinal 
hernia. Again recall the relations of the femoral ring (Fig. 490). 

Obliteration of the Femoral Ring, — Retract the upper angle of the 
wound so that you can see, divide Gimbernat's ligament freely, 
cutting horizontally and toward the pubes (Fig. 491). Poupart's 
ligament can now be approximated to the pectineus. Protect the 
femoral vein with a retractor and pass the first suture adjoining it, 
using a strong curved needle and No. 2 or No. 3 catgut. 

The needle enters the pectineal fascia, grazes the bone, comes out 
a little higher, and then passes up to the posterior surface of the liga- 



.ABDOMINAL REPAIR 



645 



ment and forward through it (Fig. 492). Place four sutures in this 
manner before tying (Fig. 493). Tie them successively from without 
inward. It is this line of suture alone that will be efficient, but suture 
the fascia if you wish, and finally the skin. 

The subsequent treatment is the same as in inguinal hernia. 

Such is the method which Veau recommends, and which has the 
great merit that it is anatomical. But there are many differences 
of opinion as to the best method of closing the femoral ring, and as 
to the advisability of even closing it at all. 




Fig. 489. — Resection of the omentum. (Guibe.) 



Ochsner enunciates the principle, applying it to the radical cure 
of femoral hernia, that circular openings in any part of the body, 
will certainly close unless kept open by a mucous or serous lining. 
Wherever, therefore, the femoral ring is well defined, he is content 
with high ligation of the sac and dissection of all the fat and simple 
closure of the wound. With a technic thus reduced to the simplest 
terms, he obtains excellent results. Unfortunately, the femoral 
ring cannot always be defined as a circular opening, and especially 
after the operation for strangulated hernia. 

Coley in the main agrees with Ochsner, but lays somewhat more 
stress on the closure of the femoral canal. 



6 4 6 



RADICAL CURE OF FEMORAL HERNIA 



The cure is the more perfect and certain, we think, if a more partic- 
ular care is given to the closure of the femoral ring, to obliteration of 
the femoral canal. Especially in case the hernia is of long standing, 
the opening large, the structures stretched and weakened. 





Fig. 490. — The neck of the sac ligated and 
cut off. Above, Poupart's ligament; below, 
the ramus of the pubes; internally, Gimber- 
nat's ligament. (Veau.) 



Fig. 491. — Femoral hernia; incision 
Gimbernat's ligament. (Veau.) 



of 





Fig. 492. — Suturing Poupart's ligament 
to pectineal fascia. (Veau) 



Fig. 493. — Suture of Poupart's ligament 
and pectineal fascia completed. (Veau.) 



Proceed as described in the case of strangulated hernia, to expose 
liberate, and ligate the sac, dividing Gimbernat's ligament to give a 
good exposure. Ligate the sac high. 

The peritoneum is now freed from contact with the abdominal 
wall, holding it back out of the way with a flat retractor. The vein 
which is freely exposed is drawn outward. 



ABDOMINAL REPAIR 



647 



Poupart's ligament is now lifted up and the free borders of the 
internal oblique and the transversalis exposed above, and Cooper's 
ligament below. It is these structures which are to be drawn into 
contact. The first suture is passed close to the femoral vein. It is 
the most difficult because the structures from within outward 
become more deeply placed. 

The remaining two or three sutures appproach the pubes, the last 
reaching up behind Gimbernat's ligament (Fig. 494). Some diffi- 
culty may be experienced in passing these sutures, for Cooper's 
ligament is quite resistant. 




Fig. 494. — Radical cure of femoral hernia. The first plane of sutures approximates the 

1 border of the internal oblique and transversalis to Cooper's ligament — the periosteum of the 

ilio-pectineal line. Gimbernat's ligament divided, the femoral vein drawn outward. (Guibe.) 



The second and superficial plane of sutures approximates Poupart's 
ligament to the pectineal fascia (Fig. 498). Thus the femoral canal 
is completely obliterated by two strong fascial planes. The super- 
ficial fascias are sutured to obliterate any dead spaces andthe skin 
repaired. 

In the case of the male or for that matter in the difficult cases in the 
female the inguinal canal may be opened exactly as in inguinal hernia. 
The cord is drawn down, the transversalis fascia divided, avoiding 
the deep epigastric artery, and the neck of the sac exposed. It is 



648 



RADICAL CURE OF FEMORAL HERNIA 




Fig. 495. — Radical cure of femoral hernia. The first row of sutures is tied and the second 
passed, approximating Poupart's ligament and the pectineal fascia. The femoral vein drawn 
to the outer side must be avoided. (Guibe.) 




Fig. 496. — Radical cure of femoral hernia by the inguinal route. The sac is dissected out, 
opened, emptied, and ligated. The cord displaced downward, the vein outward. The 
border of the external oblique drawn upward exposing the internal oblique which will 
be sutured to Cooper's ligament after the sac is cut off. 



ABDOMINAL REPAIR 649 

freed from its pouch in the femoral canal, brought out of the wound, 
opened, emptied and ligated (Fig. 496). 

The borders of the internal oblique and transversalis are approxi- 
mated to Cooper's ligament — in other words, the periosteum of the 
ilio pectineal line, avoiding the femoral vein as described above. 
Poupart's ligament is next approximatedjx) the pectineal fascia, the 
cord is replaced and the incision in the external oblique repaired and 
the operation completed as for inguinal hernia. 






CHAPTER XIV 

ENTERECTOMY. INTESTINAL ANASTOMOSIS 

Resection of a segment of the small intestine may be a necessary 
part of several emergency operations. It may be required following 
gunshot or other lacerating wounds of the intestine; it may be neces- 
sary in certain wounds of the mesentery and in the gangrene of stran- 
gulated hernia. 

Large wounds of the gut, those which carry away more than one- 
half the circumference, require resection, for any form of repair is 
likely to result in stricture. In the case of multiple perforations, it is 
safer to resect than to attempt separate repair of the orifices. A 
small wound of the omentum near the intestinal border may require 
an extensive resection, for an inch of mesentery at that level may 
contain the blood supply of 2 feet of intestine. 

Resection of the bowel implies anastomosis, and this may assume 
one of three forms: it may be end-to-end — termino- terminal, termino- 
lateral, or latero-lateral. 

The end-to-end anastomosis is preferable following resection. 
The method employed may be either by suturing — -circular enteror- 
rhaphy — or by the Murphy button or some of the other mechanical 
devices, such as Robson's bone bobbin or Frank's decalcified bone 
coupler. With the great majority of surgeons, suturing is the 
method of choice, although the casual operator may not yet be 
ready to discard the mechanical device. 

Moynihan, in his great work on abdominal operations, sums the 
matter up in this wise: "The use of mechanical appliances is no 
longer necessary; these have played their part — a most important 
part, I gratefully admit — in the development of surgical work, and 
it is now time that their surgical use should be abandoned. They 
have been useful, nay, indispensable steps in the march of progress. 
To Murphy above all other surgeons — for his instrument Js^one of 

650 



TECHNIC OF RESECTION 651 

the most ingenious mechanical contrivances ever invented — we 
should gratefully acknowledge the debt we owe. The weightiest 
argument against all mechanical aids to anastomosis is this — they 
are unnecessary. By their aid we do not accomplish anything which 
cannot be accomplished with equal rapidity and greater safety by 
simple suture. We have nothing to gain from their use and we risk 
much by leaving something behind which may be and has been the 
direct cause of danger and of death. The day of mechanical aids is 
over. The buttons and the bobbins, the elastic ligatures and the 
forceps of many forms have no more than a historical interest." 

Technic of Resection. — The first essential of this procedure is 

. that all the impaired gut be removed. Otherwise subsequent slough 

and perforation are almost a certainty. There is a limit, of course, 

. to the length of the segment which may be safely removed, but in the 

ordinary operation one need not fear to remove too much. Cases are 

;on record in which as much as 10 feet of the small intestine have 

ibeen removed with recovery. As Moynihan said, it is not so much 

;a question of how much is removed as how much is left to carry on 

the intestinal functions. 

A second requisite in resection is that the blood supply of the bowel 
be left unimpaired. Lack of precaution in this respect may nullify 
an otherwise careful operation. 

The integrity of a given part of bowel is absolutely dependent 
upon the condition of the vessels which arise from the last arterial 
. arch to supply it. It must be remembered that the vasa intestini 
, tenuis break up into a number of freely anastomosing arches, but 
^the terminal branches anastomose but little. It is this charac- 
ter of the circulation which determines the mode of section of the 
I mesentery. 

The third principle constantly to be borne in mind is that the perito- 
neum is to be completely protected from contamination by the 
•bowel contents. It is true of all the hollow viscera that their con- 
tents are more or less septic, always sufficiently so to produce perito- 
nitis. The bowel, then, must always be temporarily constricted 
- beyond the limits of the section. This is ordinarily done by means 
of intestinal clamps or by elastic ligature or by gauze strips passed 
. through a button-hole in the mesentery. 



652 



ENTERECTOMY. INTESTINAL ANASTOMOSIS 



Not only must the intestinal contents be restrained, but also tht 
field of operation must be shut off from the peritoneal cavity and 
from contact with the rest of the viscera by means of sterile com- 
presses. The larger and more deeply placed of these are not to be 
removed until the end of the operation; the smaller and more super- 
ficial should be changed from time to time as soiled. 




Fig. 497. — Resection of the bowel; showing lines of incision of bowel and omentum. 

To resect a portion of the intestine, then, begin by getting the 
injured coil well into view and pack around it with sterile compresses, 
It may be advisable as a further security now to put the patient in 
the Trendelenburg position. Strip the portion of bowel to be re- 
moved, so as to empty it, and apply a clamp well beyond each end 
of the condemned segment. The clamps are not placed directly 
across the bowel, but obliquely, so that more of the convex than of 
the mesenteric border is included. A portion of the mesentery is 
included in the bite of the forceps. 

The lines of the section are prolonged into the mesentery so that 



TECHNIC OF RESECTION 



653 



they meet just short of the nearest arterial arch. It is better to 
make the base of the mesenteric wedge even narrower than the 
■ mesenteric margin of the intestinal segment. There is then scarcely 
r any danger that the circulation will be impaired (Figs. 497, 498). 
If a lateral, instead of an end-to-end, anastomosis is in- 
tended, the technic may be varied with great advantage. Under 
such circumstances proceed in this manner: Determine the 




Fig. 498. — Resection of bowel; showing segment of bowel and omentum removed. 



lines of section; free the mesentery opposite, for a short distance 
• and apply a clamp to the bowel but not including the mesentery; 
i shift the clamp so as to flatten a segment of the bowel an inch long. 
> Ligate both ends of this segment and cut between the sutures, wrap- 
ping the stump of the healthy portion in sterile compresses. Pass 
to the other line of section and treat it in the same manner. The 
portion of bowel to be removed is now freed of its mesentery, dividing 
it parallel with, and an inch from, the gut, catching the vessels one 



654 



ENTERECTOMY. INTESTINAL ANASTOMOSIS 



by one as divided. To each of the remaining stumps a purse-string 
suture is applied for the purpose of burying the ligated ends; are 
further closed by a row of Lembert sutures (Fig. 499). Following 
this step, the lateral anastomosis, to be described further on, can 
be carried out. 

Technic of End-to-end Anastomosis. — (a) By suture. Employ two 
lines of suture. One perforates the bowel wall, brings the cut edges 
into accurate contact, and is hemostatic; it may be called the " per- 
forating' ' suture. The other passes only through the serous and 
muscular coats — -or even better the submucous — and after the man- 
ner of the Lembert suture brings the serous surfaces into contact, 
buries the perforating sutures and effectually prevents any of the 






Fig. 499. — Resection of the bowel preparatory to lateral anastomosis, showing manner of 

treating the intestinal stump. 



bowel content from reaching the peritoneal cavity. Most surgeons 
employ a straight needle and silk. Moyhihan likes the curved needle 
and celluloid thread. 

To introduce the suture begin by placing the clamps side by side, 
bringing the posterior surfaces of the bowel into contact. Con- 
nect these two surfaces by a continuous sero-serous suture, extending 
from the mesenteric border to the convex border (Fig. 500). Leave 
the thread long where tied at the point of beginning and catch it with 
forceps. On reaching point "B" leave the needle, still threaded, 
but wrap it in gauze and lay it aside for the moment. 

Now begin the perforating suture at the mesenteric margin. The 
two leaves of the mesentery separate here to encircle the bowels, 
leaving a part of the surface bare. The stitch must be passed so as to 
bring the mesentery in contact with this bare area. 



TECHNIC OF END-TO-END ANASTOMOSIS 



655 



Proceed in this manner: Pass the needle through the bowel wall 
(beginning with the right side) about % inch from the cut edge, 
entering the mucus, emerging from the serous coat just where the 
mesentery reaches the bowel. Carry the needle over and across to 
the left side, pass it through into the lumen, reversing the first punc- 
ture. Pass it next from within out, perforating the wall near the 

. mesenteric juncture, and finally perforate the right bowel wall again, 
passing from without inward. The knot is tied within the lumen 

[ of the gut at the original point of entrance. The edges of the mes- 




Fig. 500. — End-to-end anastomosis; the first part of the sero-serous or Lembert suture 
applied. Beginning the inclusive suture. (Binnie.) 

entery being thus brought together, the suture is carried continuously 
around the whole circumference of the gut (Fig. 501). The punc- 
tures are Mo to 34 2 i nc h apart and the work is facilitated by keeping 
the thread taut, which at once tightens it sufficiently and brings 
into view the site of the next puncture. The end of the suture is 
knotted, the thread left long at the beginning and thus the perfo- 
rating suture is completed. Remove the clamps. 

It remains to complete the sero-serous suture which was tempora- 
rily abandoned. It is carried from the convex border on around to 
the mesenteric border, and when that point is reached the perforating 
suture is completely buried. Knot with the thread left long in the 
beginning and held with forceps, and thus the sero-serous suture is 



6 S 6 



ENTERECTOMY. INTESTINAL ANASTOMOSIS 



completed (Fig. 502). Finally suture the rent in the mesentery. 
This must never be neglected, else it may be the site of a strangulated 
hernia. The line of suture is to be carefully wiped, the compresses 
removed, and the loop returned to the abdominal cavity. 

(b) By the Murphy button (Fig. 503). The bowel is resected as 
described above. Begin by passing a purse-string suture around the 
bowel near its cut edge, involving all the layers. The chief concern 




Fig. 501. — End-to-end anastomosis; the first part of the Lembert suture buried by the in- 
clusive suture which will be completed before resuming the Lembert A B. (Binnie.) 



is to get control of the mesentery where its layers separate. To do 
this pass the needle through one layer, on into the lumen of the 
bowel; out again through the bowel wall and through the other layer 
of mesentery (Fig. 504). 

When the suture is puckered the intermesenteric space is obliter- 
ated. Now grasp one-half of the button with forceps and introduce 
it into the end of the gut so that when the purse-string suture is 
tightened it will fall into the groove in the button. 



ANASTOMOSIS BY THE MURPHY BUTTON 



657 



Adjust the other half of the button in the same manner. The 
male half is pressed firmly into the female half, noting that all the 
edges are turned in. Strengthen the union by a few Lembert 
sutures. Repair the rent in the mesentery and the anastomosis is 




Fig. 502. — End-to-end anastomosis com- 
pleted. A and B to be knotted. (Binnie.) 




a r b 

Fig. 503 — Murphy button. 




Fig. 504. — Purse- 
ring suture (b) run- 
ng over edge of bowel 
id closing space be- 
reen mesentery (c) 
(a). (Stewart.) 



Fig. 505. — Anastomosis with Murphy button completed. 
(Binnie after DaCosta.) 



complete (Fig. 505). It may be expected that the button will pass 
about the tenth day. 

Lateral Anastomosis. — Proceed as before, bringing out of the ab- 
dominal cavity the loops to be anastomosed and pack with sterile 



42 



658 



ENTERECTOMY. INTESTINAL ANASTOMOSIS 



compresses. Each loop is clamped and the two clamps laid side 
by side so as to bring about 5 inches of the bowel walls in contact 
(Fig. 507). 

The first line of suture is to be applied nearer the convex than the 
mesenteric border and should be about 3 inches in length. Unite 
the opposed surfaces then by a sero-serous suture. The line of 





Fig. 507. — Lateral anastomosis facilitated Fig. 508. — Lateral anastomosis; first row 
by use of clamps. Continuous suture for both of Lembert sutures applied. (Binnie.) 

layers. (Binnie.) 



suture runs toward the operator, and when the line has reached, say 
3 inches, the needle is left, still threaded, and temporarily laid aside. 
The next step consists in making the openings which are to afford 
the means of communication between the two loops. A straight 
incision about 34 inch from and parallel with this line of suture lays 
open the bowel down to the mucosa. Section of these superficial 



LATERAL ANASTOMOSIS 



659 



coats leave exposed an ellipse of mucous membrane, and this ellipse 
should be trimmed out with the scissors. The other loop is opened 
in the same way. 




Fig. 509. — Lateral anastomosis; 
'-first part of the through-and- 
through suture applied (Binnie.) 



Fig. 510. — Lateral anastomosis. Applying 
last of the Lembert sutures. Interrupted in 
this case, use the continuous instead. (Binnie.) 



The adjoining edges are now to be coapted by continuous per- 
forating suture (Fig. 508). As this suture progresses the opposite 



66o 



ENTERECTOMY. INTESTINAL ANASTOMOSIS 



angle of the wound is reached, but without interruption it continues 
to draw together the more widely separated borders (Fig. 509). 

When it has reached the point of beginning, the terminal thread 
is knotted with the first which was left long, and so the perforating 




Fig. 511. — Cross-section of lateral anastomosis. (Binnie.) 

suture is finished. Remove the clamps, wipe the bowel, and now 
return to the sero-serous suture and continue with that until the per- 




Fig. 512. — Termino-lateral anastomosis. 
Clamps and continuous suture employed. 
(Binnie.) 




Fig, 5 13 . — Termino-lateral 
anastomosis completed. 
(Binnie.) 



forating sutures are completely buried or, in other words, until the 
sero-serous suture has traveled completely around the bowel and 
the terminal thread knotted with the primary suture. 



TERMINO-LATERAL ANASTOMOSIS 66 1 

If preferred, this sero-serous suture may be an interrupted instead 
of a continuous stitch (Fig. 510), but the continuous suture is more 
rapidly passed and is in every respect as secure. The main thing to 
be attained, however, is that the serous surfaces be brought into 
contact through the whole circumference of the bowel. 

Fig. 511 shows the appearance of the bowel on cross section after 
such an anastomosis. This method may be modified in many ways, 
but exemplifies really the fundamental principles involved in any 
anastomosis of the digestive tube. It is purposely stated in its 
simplest terms and shorn of detail. 

The technic of the termino-lateral form of anastomosis does not 
differ in any essential detail from that just described for the latero- 
lateral form (Figs. 512 and 513). 



CHAPTER XV 
IMPERFORATE ANUS 

A correspondent addresses the editor of the Journal of the Ameri- 
can Medical Association (September 8, 1906) to this effect: 

"Mrs. B., a perfectly healthy woman of twenty-eight years of age, 
after a normal pregnancy, gave birth to a fine eight-pound boy, well 
nourished and healthy looking, and perfect in every way except there 
was no anus nor sign of any. A small amount of meconium was 
being passed through the urethra. The next morning a local surgeon 
was called in counsel and an incision was made through the floor of 
the pelvis and dissected up along the coccyx, but no rectum was 
found nor trace of a gut until the sigmoid flexure was reached in the 
free peritoneal cavity. A large opening in the sigmoid was followed 
by a discharge of feces. No attempt was made to stitch the gut to 
the wall or the integument. The opening was not closed in any way 
and no dressing applied, except that the nurse was directed to keep 
the site of the operation sponged with a saturated solution of boracic 
acid after each evacuation of the bowels. The child nursed well after 
the operation and has continued to do so. It sleeps nearly all the 
time, but has had no elevation of temperature; the passages come 
free and the urine is passed normally. Can you suggest any means 
of treatment that will permit the child to grow up with at least a 
slight control of bowel movement?" 

That is the question which occurs to every doctor compelled to 
deal with these cases, which are fortunately rare. The little being's 
life rests upon the doctor's readiness to act; and if it survives, whether 
or not it carries a life-long disability depends largely upon his skill. 

It usually happens in the course of such cases that no meconium 
passes within a reasonable time after the baby's birth. It grows 
restless, perhaps vomits, and for the first time it is suspected that 
there is some abnormality about the rectum or anus, which an exam- 

662 



OPERATIVE TECHNIC 



663 



ination verifies. It is imperative to relieve the condition at once and 
if no specialist is within reach, the doctor must undertake it. He 
may find it quite easy or he may find it impossible. 

In the first instance, the anus and rectum may be both fully devel- 
oped, but in passing a finger or probe into the orifice, a thin bulging 
membrane can be felt, apparently almost ready to burst when the 
infant cries. A sharp-pointed bistoury, wrapped and introduced 
along the finger or a grooved director, easily punctures the membrane 
followed by a free passage of meconium; and thereafter the bowel 




W^ 



Fig. 514. — Incision for imperforate anus. (Veau.) 



: readily empties itself. The mother is directed to dilate the opening 

j daily with her little finger, and that, with an occasional stretching 

i with a bougie, is sufficient. 

In another case there may be no depression where the anus should 

; be. The median raphe extends unbroken from the scrotum to the 
coccyx. The anus is absent and it may be practically impossible 
to tell how high up in the pelvic cavity the rectal cul-de-sac may be; 

1 and yet it is one's duty to hunt for it through the perineum. 

Operation. — Put the patient on its back with thighs flexed and 
pelvis elevated — -in short, in the lithotomy position. Employ a light 
chloroform anesthesia, not that there is any danger if the anesthesia 
is carefully conducted, unless, indeed, the operation has been too long 



(>(>4 



IMPERFORATE ANUS 



delayed, but that a little straining on the patient's part may help to 
locate the bowel. 

Make a median incision from the base of the scrotum or from near 
the posterior vaginal wall to the coccyx, which must be exposed 
(Fig. 514). A number of eventualities may present: 

(1) One may find immediately beneath the skin some of the fibers 
of the external sphincter, a favorable indication. Split these fibers 
by blunt dissection. Free incision may spoil their usefulness. Be- 
neath the muscular layer appears the lobulated fatty tissue peculiar 
to the new-born, which is to be next divided. Here one must go 




Fig. 515. — Retention suture. (Veau.) 

slowly, keeping in the middle line and all the time working toward 
the coccyx. The danger is in front. If toward the hollow of the 
sacrum, a fluctuating pouch is felt or a brownish rounded tumor is 
seen, one breathes easy, knowing that the imperforate gut is within 
reach. But do not be in a hurry to open the gut. It is first to be 
secured by passing a suture on each side of the middle line or by 
catching the bowel wall with forceps. The suture should not per- 
forate the bowel. 

Making gentle traction on the bowel, proceed to free it by careful 
blunt dissection. Do not use knife or scissors to divide what seem 
to be fibrous bands, for it is possible they contain the blood supply 
of the bowel; and, if divided, dangerous bleeding may occur or the 
tissues become gangrenous. 



OPERATIVE TECHNIC 



665 



As the pouch is freed, it is gradually pulled down into the wound; 
and if they were not passed before, two sutures are now passed with 
which eventually to fasten the gut to the skin opening (Fig. 515). 
Now is the time to open the pouch and let the meconium flow out. 
It may require several minutes for the bowel to empty itself. Evert 
the mucous membrane, enlarging the bowel wound a little if neces- 
sary. Suture the mucous membrane directly to the skin; no other 
tissues should intervene (Fig. 516). 

Irrigate thoroughly and apply a gauze dressing, which is changed 
as often as soiled. The functional result is often surprisingly good. 




Fig. 516. — Mucocutaneous suture. (Veau.) 



Broncho-pneumonia may develop when the operation has been too 
long delayed and septic absorption has begun. 

(2) The pouch cannot be drawn down. In that case when the bowel 
is opened the discharge will have to flow over the raw surfaces of the 
flesh w r ound which will need to be kept open with bougies. Infec- 
tion is a constant danger, not to speak of lack of control of bowel 
movement. 

Better than to leave the wound in this condition, the coccyx and a 
part of the sacrum may be removed and the gut brought out poste- 
riorly. Still better, open the peritoneal cavity, find and draw down 
a loop of the sigmoid to fasten in the wound. 

(3) The ponch cannot be found. Obtain more room by resecting 
the coccyx, follow the sacrum a little higher, open the peritoneal 



666 IMPERFORATE ANUS 

cavity and search for the cul-de-sac; if possible, draw it down into 
the wound and suture. 

If all these measures fail, there is nothing to do but make an arti- 
ficial anus in the inguinal region. Indeed, there are those who advise 
this from the first with the idea that later the operation for the con- 
struction of a normal anal orifice can be better undertaken. 

Tuttle says (Diseases of the Anus, Rectum, and Pelvic Colon) that 
where there is no evidence that the rectal pouch can be easily reached, 
and where the child is in an enfeebled condition with distended ab- 
domen, fecal vomiting, and nausea in progress, one should not hesi- 
tate to choose the abdominal route, perform an inguinal colotomy 
at once and thus afford an immediate exit to the intestinal contents, 
and an escape for the gases which are causing the distention and the 
constitutional disturbance. 

To this same volume the reader is referred for a full discussion of 
these problems, and for consideration of those other forms of imper- 
fect development in which the anus has abnormal openings. Such 
cases are not strictly emergencies, for usually there is a partial means 
of escape for the bowel contents. 



CHAPTER XVI 

TORSION OF THE PEDICLE OF OVARIAN OR UTERINE 
TUMORS; OF THE SPERMATIC CORD; OF THE PEDI- 
CLE OF THE SPLEEN; OF THE OMENTUM 

Torsion of the pedicle of an ovarian or uterine tumor may be either 
chronic or acute; in the one case developing so slowly as to produce 
no symptoms or even no effect upon the tumor unless merely to in- 
hibit its growth, for in the adhesions are new sources of nutrition; 
in the second case developing suddenly and producing a train of 
symptoms that demand immediate relief. The acute cases alone, 
then, are to be regarded as emergencies. 

Cysts of the ovary, especially those which are spherical, non-adher- 
ent, and connected by a long pedicle, are most liable to this accident. 

Kelly finds two causes for this rotation. The first of these is in 
the effort of a large cyst to accommodate its convex surface to the 
concavity of the distended anterior abdominal wall. The second 
cause is found in contractions of the anterior abdominal wall, which 
act upon the part of the tumor nearest the middle line. The effect 
of the force thus applied is to rotate the tumor. In the case of 
smaller tumors lying in the pelvic cavity it is likely that unusual 
movement in the intestine or readjustments of the pelvic viscera may 
produce the same effect. Kelly quotes Kiistner to the effect that 
tumors of the right side, as a rule, rotate from left to right, while 
left ovarian tumors rotate from right to left. 

The diagnosis of acute torsion is not difficult if an ovarian cyst is 
known to be present. If such a tumor was previously unsuspected 
the certain diagnosis may be impossible, especially if the case is 
seen late and general peritonitis is developing. 

The symptoms, as a rule, arise without warning. There are severe 
colicky pain, vomiting, marked constipation, and the appearances of 
collapse. Abdominal rigidity and tension rapidly increase. This is 

667 



668 TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS 

true of the more urgent cases. In general, the severity of the symp- 
toms vary with the degree of torsion. 

Appendicitis and acute intestinal obstruction present the greatest 
difficulties in differential diagnosis which it is desirable to make, not 
to determine the advisability of operating, but to determine before- 
hand the kind of operation one is to undertake. Ranzi (Berliner 
klin. Wochenschrift, Jan. 6, 1908) reports four cases of torsion of 
ovarian cyst which were not differentiated from appendicitis, except 
in one case, before the operation, and in this case by the pains in 
urinating. In three of the cases there had evidently been mild 
attacks of torsion which had subsided and which had been diagnosed 
as catarrhal appendicitis. 

The treatment is operative, and, as has been indicated, the operation 
must often begin as an exploratory laparotomy, for though the symp- 
toms indicate the seriousness of the case they may not reveal its 
character. Delay is dangerous in these cases, and seldom will one 
regret having operated early, for nearly always the lesions found 
exceed the expectation. 

The appearances once the abdomen is opened will depend upon the 
size of the tumor, the degree of torsion, and the time of intervention. 
Usually the tumor will be found enveloped in loops of intestine bound 
together by soft adhesions (Fig. 517). 

These adhesions are to be carefully separated, and one must pro- 
ceed with prudence for the cyst may be filled with pus and its walls 
may be friable. The intestines, detached, are to be held out of the 
way with compresses and the tumor thus brought into view. Its 
nature may be at once apparent in spite of the fact that it is dis- 
colored, dark red, or even black. If it is a cyst not quite so large, 
it may resemble a dilated cecum. Its attachments are carefully 
broken up, and gradually working toward its base the pedicle is 
finally defined. 

An effort is now made to lift the tumor out of the abdominal 
cavity, and there need be no hesitancy in enlarging the abdominal 
incision if necessary. Usually it is to be lifted out with the two hands 
applied to its base. Occasionally only after its pedicle is untwisted 
is it possible to deliver it. 

Next the pedicle is tied near its point of implantation, divided, 



TORSION, OVARIAN CYST 



669 



and thus the tumor is removed. If there are no evidences of infec- 
tion the abdomen is to be closed without drainage. 

Tumors springing from the uterus are much less likely to become 
twisted. Yet, in the case of large non-pedunculated fibroids, the 




Fig. 517. — Torsion of the pedicle of an ovarian cyst. {Montgomery.) 

uterus itself may be rotated and give rise to symptoms which de- 
mand relief. In such a case the intervention may be quite complex. 
In some instances a myomectomy may be sufficient. The uterine 
wall is incised over the long axis of the tumor, which is exposed and 
peeled out, and the hemorrhage checked by suture of the uterine 



670 TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS 

wound. The uterus may still tend to rotate and may require 
fixation. 

In still other instances, hysterectomy, either supra-vaginal or 
complete, may be the procedure necessary for relief. This will be 
the case when the condition of the uterine wall after removal of the 
tumor would preclude repair. 

Harsha reports to the Chicago Medical Society (Annals of Surgery, 
Nov., 1905) a case of torsion of the pedicle of an ovarian cyst in a 
woman of thirty-three, who for several years at intervals had had 
attacks of intestinal obstruction, accompanied by pain and vomiting, 
lasting for three or four days. 

Her last attack began suddenly with pain, vomiting, constipation, 
tenesmus, accompanied by the symptoms of shock. At the end of 
four days the abdomen was opened. A cyst, the size of an orange, 
with twisted pedicle was removed. There was neither peritonitis 
nor gangrene. There had been no further indications of obstruction. 

In a second case the cyst was as large as a fetal head and black 
to within an inch of its implantation. 

Ochsner, commenting on these cases, says that symptoms of ob- 
struction are not uncommon in such cases and that the history is 
often that of volvulus. 

He cites a case in which the abdomen had been opened by a prac- 
titioner who believed he was dealing with intestinal obstruction. 
Having opened the abdomen, however, he discovered a large black 
tumor. Disconcerted, he stopped his operation, hurriedly trans- 
ported the patient to the Augustana Hospital where Ochsner com- 
pleted the work. 

The doctor performing an emergency laparotomy must not have 
his mind too definitely fixed on one diagnosis. Expecting one thing, 
he must still have in view the possibility of having to deal with one 
or more of a variety of conditions, and so will not be taken completely 
unaware. 

John Cahill and Sir William Bennett give the history of a case 
which well exemplifies the difficulties of diagnosis, the occasional 
complexity of treatment, and the dangers of delay (London Lancet, 
Dec. 8, 1906). 

The patient/ aged seventeen, was suddenly seized with abdominal 



TORSION OF THE SPERMATIC CORD 67 1 

pain. There was some tenderness and resistance over the right iliac 
fossa. The temperature was 98. 8°, the pulse 90. Bowels were 
emptied by enemata, but the pain continued. On the third day 
the temperature ran up to 101.8 and the pulse to 120. 

An operation was still refused until at the end of a week the 
patient's condition had become very grave. An operation for appen- 
dicitis was then performed and the appendix found adherent and 
rilled with pus, in addition to other evidences of chronic disease. 
Further examination revealed a dark, firm mass occupying the upper 
part of pelvic cavity and intimately adherent to the bladder and 
uterus. Exposed by extending the incision, it proved to be an ovar- 
ian cyst the size of a cocoanut with a thick pedicle twisted upon 
itself for three-fourths of a turn. Its walls were thin and blackish, 
and its contents mainly decomposed blood. The cyst was removed 
and the patient recovered. 

Dr. Cahill, commenting on the case, remarked that the situation 
of the cyst was unusual in that it was wedged between the bladder 
and uterus, whereas one expects to find such a tumor in Douglas' 
pouch. 

Sir William Bennett says that although cases not infrequently 
operated upon for appendicitis prove to be cases of torsion, yet the 
coexistence of the two conditions must be very rare. He suggests 
that in this case the appendicitis, by aggravating the intestinal 
peristalsis, had displaced the tumor with consequent torsion of its 
pedicle. 

Angus (British Medical Journal, Jan. 27, 1906) reports an attack 
in a child of six, beginning with pain, vomiting, and abdominal dis- 
tention. By the rectum a mass was palpable in the cul-de-sac. A 
diagnosis of appendicitis with abscess formation was made. Opera- 
tion. The appendix was inflamed at the end where it was attached 
to a dark cytic swelling in Douglas' pouch. It was the right 
ovary darkly congested, large as a duck's egg, and with twisted 
pedicle. Its contents showed it to be an ovarian dermoid. 

TORSION OF THE SPERMATIC CORD 

Malformations and imperfect descent predispose to rotations of 
the testicle — an accident rare yet none the less to be borne in mind 



672 TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS 

as a possibility. The exciting cause is usually to be found in trauma. 
A heavy lift or strain may produce it. 

It is readily comprehended that an incompletely descended tes- 
ticle shifting backward and forth through the external ring could be 
forcibly rotated. The rotation may occur in two ways: either the 
testicle with its tunica vaginalis may be turned or the testicle alone 
may rotate. The spermatic vessels, nerve, and vas deferens are 
all involved in the resulting torsion. 

The symptoms range from moderately severe to grave. Pain, 
nausea, vomiting, constipation, and tympanites signalize the attack, 
and soon the signs of local inflammation appear. 

In the more serious cases the pain begins abruptly and persists. 
It usually radiates from the inguinal region and lower part of the 
abdomen, and may be intense or even produce shock. The con- 
stipation is usually relieved by enemata. 

The presence of a painful tumor in the inguinal region together 
with the symptoms point to strangulated hernia and torsion of the 
spermatic cord equally, and the differential diagnosis may be a 
matter of difficulty. The pain is much more intense and sudden in 
its onset than epididymitis. The cord, in torsion, can be felt tender 
and swollen; it cannot be felt in strangulated hernia. Of course in 
strangulated hernia the constipation is absolute. 

Once the diagnosis is assured, an effort to untwist the cord should 
be made and occasionally it will succeed. It is recorded of patients, 
who, having had several attacks, learn to give themselves relief. If 
manipulation fails it is imperative to operate without delay, for there 
is danger of gangrene of the testicle. 

An incision extending from near the external ring follows the cord 
down toward the base of the scrotum. Layer by layer the tissues 
are divided until the tunica vaginalis is reached. The tissues are 
often edematous, reddened, and swollen. The tunica presents itself 
as a thin-walled sac. Open it and drain away the serum and the 
testicle will be found, possibly deformed, perhaps difficult to recog- 
nize, and above it is the twisted cord. 

Seize the testicle and rotate it from right to left in order to relieve 
the torsion and restore the circulation. The further procedure will 
depend upon the integrity of the testicle. If its violet color fades, 



TORSION, PEDICLE OF THE SPLEEN 673 

if the congestion diminishes, it is almost certain the testicle will 
recover, and it is therefore to be preserved. If it is black or mottled 
or flaky, remove it by tying the cord above the torsion (see Castra- 
tion). If its integrity is doubtful, preserve the testicle but provide 
ample drainage for the tunica vaginalis. 

Lichtenstern, of Vienna, reports a case of torsion of the spermatic 
cord in a man of forty-six, which began with lifting a heavy load. 
The scrotum soon became enlarged, and vomiting and constipation 
ensued. A diagnosis of inguinal hernia had been made, and efforts 
to reduce had failed. 

At the time of entrance at the hospital his temperature had reached 
102 and his pulse was bad. In the scrotum was a large tense tumor 
and in the inguinal canal another smaller. 

On opening the scrotum an enormously swollen, turgid testicle 
was found whose spermatic cord was twisted to 360 degrees. Part 
of the omentum was found at the internal ring. The testicle was 
untwisted and removed, the cord resected and the inguinal canal 
closed as in herniotomy. 

TORSION OF THE PEDICLE OF THE SPLEEN 

The pedicle of the spleen may become twisted in cases of wander- 
ing spleen. As in other varieties of torsion, it may develop slowly, 
producing no marked symptoms and resulting only in congestion of 
the organ and increase in size. Developing suddenly it is accom- 
panied by the symptoms of general peritonitis or intestinal obstruc- 
tion, and collapse. It may be mistaken for one of these conditions. 
The tumor may suggest subphrenic abscess. 

As Moynihan says, in the great majority of cases, splenectomy 
is the better course to pursue, and this is especially true when throm- 
; bosis of the splenic vessels, infarcts in the spleen, gangrene or peri- 
tonitis upon or around the spleen are present; when also the organ is 
enlarged, it should be removed, for even though the pedicle be un- 
twisted, it is useless to try a splenopexy. 
The result of fastening in place a small wandering spleen is doubt- 
: ful. If it is enlarged, failure is certain. Fortunately, as Hartmann 
' has pointed out, a displaced spleen is usually not at all difficult to 
remove because the lengthened pedicle permits of ready delivery; 

43 



674 TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS 

and the after-effects are not so serious as those which attend removal 
for organic disease. (Splenectomy, page 550.) 

TORSION OF THE OMENTUM 

Torsion of the omentum must naturally be a rare condition, and 
yet is to be thought of when symptoms of intestinal obstruction arise 
in those who have a hernia or are obese. 

Torsion of the omentum as might be expected is very painful. 
The pain, which is probably due to the plugging of the omental ves- 
sels, may simulate appendicitis. It is not important that the differ- 
ential diagnosis is sometimes not made, for the symptoms indicate 
operation. 

Rinchea and Corner describe a case in the British Medical Journal, 
Jan. 20, 1906. The patient, a man of forty-eight, had had a hernia 
for thirty-seven years, and had worn a truss for thirty- three; the 
hernia had been reducible and painless. He was suddenly seized 
with pain, and the hernia became irreducible. The pain increased, 
and the tumor as well, though after two days the bowels moved, a 
circumstance which ruled out strangulated hernia. The temperature 
remained 99 , the pulse 102. The skin over the lower part of the 
abdomen and inguinal region became reddened and the region tender. 
An incision over the inguinal canal found the tissues inflamed, and 
on opening the hernial sac a small mass of omentum was found 
twisted on itself five times, but not constricted at the internal ring. 
The mass was resected, and the radical operation for hernia 
performed. 

In another case, the patient, a man of forty-five with recent direct 
hernia, a mass of omentum was found, pedunculated, the size of a 
walnut, and containing a hemorrhagic cyst. 

Cullen, of Baltimore (Johns Hopkins Hospital Bulletin, Dec, 
1905), reports a case occurring in a very heavy man. The patient, 
a railway conductor, had found it necessary to eject a recalcitrant 
passenger and succeeded only after a struggle. In a few hours he 
had developed the symptoms of appendicitis. 

At the operation a gray, vascular, nodulated mass was found 
which ended above in a tightly twisted pedicle and which on removal 
proved to be the omentum. 



CHAPTER XVII 
RUPTURE AND HEMORRHAGE OF TUBAL PREGNANCY 

Rupture of the sac of an ectopic gestation is far from being a rare 
accident (Fig. 518). When it occurs, it is a major emergency, one in 
which the doctor, isolated though he may be, must act and without 
delay. Eighty-five per cent, of these cases operated upon recover; 
85 per cent, of those treated by expectancy die. These figures 
are in themselves sufficient argument, but when we add that the 




Fig. 518. — Ruptured tubal pregnancy. Clot protruding from sac. {Montgomery.) 

gravity of the condition grows out of hemorrhage, the reason for im- 
mediate intervention must be admitted by all. Even in case the 
hemorrhage tends to cease spontaneously, the urgency is scarcely 
J less pressing to prevent infection. For, from a diseased tube or a 
: stagnant fecal current, bacteria may escape to find a culture medium 
in the blood free in the peritoneal cavity. 

That the diagnosis of an extra-uterine pregnancy, even when sus- 
pected, is difficult, no one will deny. After the most careful exam- 
ination, one may not avoid error. More often, the condition 
is not even suspected until rupture occurs. 

675 



676 RUPTURE AND HEMORRHAGE OF TUBAL PREGNANCY 






A tubal pregnancy may be unrecognized, but there can be no 
excuse for overlooking a ruptured tubal pregnancy. It can scarcely be 
mistaken for anything else. Even if we admit that exact diagnosis 
may be impossible, yet the indications for intervention are unmis- 
takable. And that, after all, is the important thing. One does not 
do grave emergency operations on mere impressions or suspicions 
or the fear that such and such may be the case. We must have a 
clear clinical picture in mind. 

The attack comes on suddenly. There are pain, shock from the 
peritoneal tear, and vomiting, suggestive of acute intestinal obstruc- 
tion. One might also think of appendicitis or a renal calculus. 
There is often a bloody uterine discharge. Brickner says of the pain 
that it is usually localized over the site of the lesion. It has no 
definite character; it may be cramp-like over the affected tube; it may 
simulate labor pains; it may be sharp and sudden. The usual symp- 
toms of pregnancy may be present, but their absence does not argue 
against the extra-uterine pregnancy. We have, as yet, no definite 
data by which we differentiate between the various forms (Medical 
Standard). The history of the case and, finally, the signs of progress- 
ive internal hemorrhage point to the nature of the accident. The 
pulse grows more rapid and feeble, the temperature falls, the features 
are blanched, dyspnea appears and all the symptoms of collapse. 
Vaginal examination completes the diagnosis. One may find the 
uterus but little enlarged, but on one side or the other, rising out of 
the retro-uterine pouch, a boggy mass of variable size is felt. Dixon, 
of St. Louis (Interstate Medical Journal), says that in fifteen cases, he 
found the pregnancy on the right side in all but one, and this patient 
had the peculiar fortune to have one on both sides. The right side 
was relieved by operation, and six months later the left side necessi- 
tated a second operation. Dixon adds that rigidity of the abdomi- 
nal walls was present in most of these cases, though the absence of 
rigidity is often named as a differential diagnostic point. 

There may be an element of confusion. Vineberg, of New York 
(New York Med. Jour., Feb. 22, 1906), reports two cases out of his 
fifty-three in which there was a combined intra- and extra-uterine 
pregnancy. He notes that a persistence of uterine bleeding after an 
operation for extra-uterine pregnancy should suggest the possibility 



OPERATIVE TECHNIC . 677 

of an intra-uterine gestation. He adds, with respect to diagnosis of 
the condition generally, that amenorrhea, followed later by pain and 
irregular uterine bleeding, should always put one on his guard. 

From the history, then, and from the physical examination one 
must diagnose the condition. On the signs of progressive internal 
hemorrhage the decision to operate immediately is based, and one 
should scarcely ever deem it too late, for even in the face of the most 
menacing conditions, we must hold bravely to the last resource in 
which, even in the desperate cases, there is often safety and life. 

Operation. — AsLejars says, the operation is moving and dramatic, 
but presents no especial difficulties if one but keeps cool and knows 
what is to be done. 

Instruments. — The instruments necessary are scalpel, scissors, 
artery forceps, two long clamp forceps, two retractors, and curved 
needles. 

General Anesthesia. — -General anesthesia is necessary and must be 
closely watched. A continual hypodermoclysis is an excellent means 
of combating the combined effects of shock and anesthesia. It 
should not be begun, however, until the hemorrhage has been 
controlled. 

Antisepsis. — -It is scarcely necessary to say that it is of little use to 
save the patient from hemorrhage to die a few days later from sepsis. 
The peritoneal cavity, under the conditions assumed, is a dangerous 
culture medium. 

The Trendelenburg position is almost indispensable, and if neces- 
sary may be improvised. 

Incision. — A median incision extending from the umbilicus toward 
the pubes is made. Do not wound the bladder, which may be 
pushed upward and forward. This, however, is not particularly 
serious unless the wound should be overlooked. Waste no time. As 
soon as the peritoneum is opened, catch its edges with artery forceps 
and enlarge the orifice upward and downward. Do not try to sponge 
out the cavity. Without regarding the clots, which may mask the 
viscera, plunge a hand into the pelvic cavity and locate the uterus, 
which is easily recognized. To one side, a thick, doughy or friable 
mass will be felt. Slip your fingers under it, break the adhesions, and 
enucleate it. This will empty the retro-uterine pouch — -the cul-de- 



678 RUPTURE AND HEMORRHAGE OE TUBAL PREGNANCY 

sac of Douglas. Feel with finger and thumb for the pedicle and, if 
possible, pull the entire mass up into the wound and clamp. If the 
mass is not adherent, a single clamp enclosing the broad ligament 
from the outer side and passing under to include the tube will suffice 
(Fig. 519). If there is too much adhesion, clamp on either side 
of the pedicle. When the clamps are placed, the chief end of the 
operation has been attained. Do not waste time trying to catch the 
bleeding points, but ligate en masse. 




Fig. 519. — Forceps applied to the tubo-ovarian pedicle. Trendelenburg position. (Veau.) 

Ligate the pedicle. With a blunt, curved needle armed with No. 3 
catgut, transfix the pedicle close to the cornu of the uterus, between it 
and the forceps (Fig. 520). Ligate and then carry the ligature 
around the lower segment of the pedicle and tie again, directing the 
assistant to pull up on the clamp, and finally carry the ligature 
around the entire mass and tie a third time. Preserve the ends of 
the ligature. Resect the tumor and lift up the stump by means 
of the threads to see if there is any bleeding (Fig. 521). This ligature 
stands between the patient and death. If two clamps have been 
used, it will be necessary to ligate " en chaine." 



OPERATIVE TECHNIC 



679 



Now clean out the clots, mop out the blood, and lower the pelvis to 
drain the upper part of the abdominal cavity. The quantity of 
blood is often enormous. If the patient is very weak, do not prolong 
the task of cleansing it all out; yet in the long run, it is better to take 
the time to cleanse out the fossa and wipe the intestine and omentum, 
for then the abdomen may be closed without drainage. 




Fig. 520. — First ligature applied. (Veau.) 

Drainage. If there is oozing, apply a gauze drain at the site of the 
tumor, and insert three or four drainage-tubes into different parts of 
the cavity to carry out the blood left behind. Do not forget to fix 
the drains, lest they be lost in the abdomen. 

Suture the wound partially, unless able to dispense with drainage, 
in which case suture completely. Apply a dry dressing of gauze and 
absorbent cotton. Inject salt solution. After twelve hours, change 
the dressing, which will probably be saturated; thereafter change 
daily. About the seventh day the tubes may be shortened, and 
about the fifteenth day, or often sooner, altogether removed. 

Interstitial tubal pregnancy (Fig. 522) may occasionally be met 
with and present complications. A case described by O. G. Pfaff, of 



6So 



RUPTURE AND HEMORRHAGE OF TUBAL PREGNANCY 



Indianapolis (Western Clinical Recorder, March, 1903) illustrates 
the subject. On opening the abdomen a large reddish bag presented, 
which seemed to develop from the right wall of the uterus, involving 




Fig. 521. — Ligation and division of the tubo-ovarian pedicle. (Veau.) 




Fig. 522. — Tubo-ovarian pregnancy. (Montgomery.) 

the right tube. In order to minimize the hemorrhage as well as to 
secure the tumor, the upper portion of the broad ligament was 
clamped and another clamp placed to the left of the tumor passing 



OPERATIVE TECHNIC 68 1 

obliquely across the fundus and including the uterine artery. The 
sac was now incised at its summit and the fetus, membranes, and 
placenta turned out. No ligatures were required. The sac was 
partially sutured, a drainage-tube fastened in its cavity and brought 
out through the lower angle of the abdominal wound. The drainage- 
tube was removed on the fifth day, and recovery was complete. 

In certain of these cases the hemorrhage may be very difficult to 
control. A " V" shaped section from the uterus in the region of the 
cornua with firm suturing may succeed. 

Finally in more obdurate cases a hysterectomy may be necessary. 



CHAPTER XVIII 
CESAREAN SECTION 

Cesarean section, designed primarily as an operation to save the 
babe after the mother's death, is to-day of far broader application. 
Without considering its exact indications, which for that matter the 
whole profession is not yet agreed upon, it may be stated broadly 
that it is the method of choice when the child cannot otherwise be 
delivered alive. Unfortunately at the present time it is usually what 
it should not be, viz., an emergency operation. 

The Technic of Operation. First Stage: Laparotomy. — Incise 
the abdominal wall. The incision extends in the middle line to 
within 2 inches of the pubes and should be at least 4 inches in length. 
If the uterus is to be brought out of the abdominal wound it will re- 
quire to be longer. The peritoneum is to be exposed and opened up 
in the usual manner. The abdominal walls are often quite thin. 
As soon as the peritoneum is opened the uterus pushes into view. 
Correct any lateral deviation. Hurriedly wall off the uterus with 
sterile compresses, or deliver the uterus, protect with sterile com- 
presses and suture the upper angle of the peritoneal wound. 

Second Stage: Incision of the Uterus. — Keep exactly in the middle 
line. Make a small incision in the uterus at the level of the lower 
end of the abdominal wound that you may not later encroach upon 
the lower segment of the uterus. 

The peritoneum and superficial muscular layers are divided with 
the bistoury, the deeper muscular fibers separated with the fingers. 
Make a small opening in the mucous membrane. Through this 
wound slip a finger into the uterus and on it as a guide divide the 
uterine wall with scissors toward the summit; the incision should be 
6 or 7 inches long. If the placenta is attached over the median line, 
cut through it also. It makes no difference if the work is done 
rapidly. 

682 



OPERATIVE TECHNIC 683 

Third Stage: Deliver the Child. — Slip the hand into the uterus. 
Grasp the feet, delivering the breech first. Clamp the cord in two 
places and cut between. 

Fourth Stage: Remove the Membranes. — -As soon as the child is 
delivered the uterus contracts and often the placenta is detached at 
once. If not it must be peeled off with the fingers. 

Fifth Stage: Suture the Uterus. — -Repair the uterine wall with 7 or 8 
interrupted catgut sutures deeply placed but not reaching the mu- 
cosa; or suture the mucosa first. Complete the repair by a few 
superficial sutures. Suture is the best means of hemostasis, but 
the bleeding is usually inconsiderable, especially if the uterus is 
brought outside and bent toward the pubes. 

Sixth Stage: Suture the Abdominal Wall. — Repair the peritoneum 
| with continuous suture; the fascias with chromic gut or plain 
catgut; the skin with silkworm-gut. 

These are the principles involved, bared of details which, of course, 
vary with the operator and with the environment. Examples are not 
wanting in current literature. A few will serve to bring out practical 
< points. 

Lanphear, of St. Louis (American Jour. Surgery, Dec, 1906), 
formulates a technic for country practice. The operator should have 
a physician for assistant, or a trained nurse. The anesthetic should 
be given by a physician. 

Instruments. — Vaginal retractor (for cleansing the vagina), knife, 
scissors, 4 hemostats, needles, chromic catgut No. 2, silkworm-gut, 
safety-pins. 

The containers for the solutions must be boiled and singed with 
1 burning alcohol — -one for bichloride, 1 to 2000. one for alcohol, and one 
for sterile water, a small dish or two for the instruments. 

Dressings and Sponges. — -Boil 15 yards of gauze and 12 towels free 
from fringes. 

Preparation of Patient. — Pubes and vulva shaved. Abdomen 
scrubbed. When the anesthesia is complete scrub the vagina with 
gauze and soap and water, followed by alcohol. 

Preparation of the H ands . — They are to be scrubbed for five minutes 
before disinfecting the patient and for five minutes after, followed 
by immersion in alcohol and then in the bichloride solution. Again 



684 CESAREAN SECTION 

sponge the abdomen before covering the field with four sterile towels 
fastened with sterile safety-pins. 

Abdominal Incision. — -Deliver the uterus and surround with four 
towels wrung out of very hot water. Protect the edges of the wound 
with sterile towels packed in around the uterus. 

Incise the uterus; deliver the child; clamp and cut the cord. The 
anesthetist may now look after the child if there is no one else to do so. 
Be careful in handling the child that your hands do not come in con* 
tact with anything not sterile. Deliver the placenta, mop out the 
uterus; suture. Lanphear advises a final row of Lembert sutures for 
the peritoneal covering of the uterus. Repair the abdominal wall; 
dress as usual; pack the vagina lightly and treat subsequently as 
after any other confinement. Brown, of Manchester, N. H., recom- 
mends practically the same procedure (American Jour. Surgery, 
Feb., 1907). He observes that the uterus should be kneaded for a 
moment to stimulate contraction. He uses in suturing the uterine 
wall, a row of twenty-day chromicized gut sutures, passing through 
all the layers a second row of Lembert sutures of silk. 

Paul Martin, of Indianapolis, reports a case (Medical Record, Oct, 
27, 1906), Operated after twelve hours of labor complicated by 
eclampsia and a narrow pelvis and in which the bladder was greatly 
distended and which could not be emptied by catheter. The bladder 
extended half-way to the umbilicus. The uterus was emptied through 
a 4-inch incision and the bleeding controlled by the assistant who 
grasped the cervix. The uterine sutures employed by Martin were a 
double row of interrupted muscular sutures of chromic gut and a 
continuous chromic gut for the serous coat. The bladder was 
not injured and afterward easily emptied. Mother and child both 
survived. 

S. A. Reynolds (Gaillards Southern Medicine, Feb., 1905) reports 
an operation which, as he says, illustrates the principle that we should 
never be afraid to put forth an effort to relieve our patients when 
absolutely demanded, however hazardous and difficult the inter- 
vention and however meager the means at our command. Place, 
a log cabin with one room, lighted by a lamp without chimney. 
Patient, a colored girl of thirteen with pelvic diameters less than 2 
inches; labor for twelve hours with a midwife in attendance. Both he 



OPERATIVE TECUM ( 685 

and Dr. Keen, with whom he consulted, realized the urgency, but 
neither had ever done a laparotomy. Their equipment consisted of two 
pocket cases of instruments, carbolic acid ; a few ligatures, an earthen 
pitcher and bowl, with teakettle of hot water. They sterilized their 
instruments and hands in carbolic solution. Patient was laid across 
the bed with feet on the floor. The abdomen washed. While Dr. 
Keen gave the chloroform Reynolds made an incision from the 
umbilicus down. The sides of the abdomen were pressed against 
the sides of the uterus to prevent bleeding into the abdominal 
cavity, and the uterus opened and emptied. 

One suture was put in the uterus. Abdominal wall closed with 
silk. On the fourth day the temperature was 103. 5 , pulse 150, resp. 
36, but the symptoms of infection subsided and by the fourth week 
the patient, was well. 



CHAPTER XIX 

RUPTURE OF THE URETHRA 1 

By a fall astride a hard or sharp-margined object, by accidents of 
saddle or bicycle, by a kick or blow, by a fracture of the pelvis, the 
urethra may be ruptured. The urethral canal is forced up against 
the pubic arch or against the sharp edge of the triangular ligament, 
and is lacerated while the more elastic integument of the perineum 
escapes. 

Any part of the urethra may suffer, although usually only one part 
is involved in a given case. The prognosis, and in some degree the 
treatment, depend upon the portion injured, though the exact loca- 
tion is not always easily determined. 

Again the prognosis and treatment depend upon whether the 

1 "We consider it unnecessary to speak of the medical treatment which is abso- 
lutely valueless, and while the mechanical treatment has been in favor even with 
the surgeon, it must be condemned if it becomes a general procedure. 

The introduction of sounds and catheters into a lacerated urethra will almost 
invariably be followed by infection at the point of laceration, notwithstanding the 
aseptic conditions under which the catheterization is performed. The general 
practitioner has been accused of inefficiency and carelessness in sterilizing his in- 
struments. While this is true to some extent, it will be seen later, when speaking 
of the Bacteriology of the Urethra, that a small aseptic instrument may cause 
infection because the traumatism produced by the passage of a sound increases 
the virulence of the urethral, flora, which normally is in a semi-saprophytic 
state of life. 

On the other hand, the general practitioner with less ability in the handling of 
sounds, especially when the urethra is inflamed and edematous, will cause false 
passages, increase the liability of stricture at the point of laceration and predis- 
pose the deep structures to infection and its consequences. It is our object to 
urge early surgical treatment in these cases and rational treatment of the later 
consequences. The expression, " traumatic stricture," must disappear from the 
medical vocabulary if the intervention in acute cases be immediate and rational. " 
— Surgery, Gynecology, Obstetrics, Oct., 1906. Neff and Schrayer, Murphy's 
Clinic, Chicago. 

686 



DIAGNOSIS OF RUPTURE 687 

rupture is total or incomplete, for upon the degree of laceration 
depend the rapidity of extravasation and later the dimensions of 
the stricture. 

These, then, are the dangers: extravasation of urine, and in its 
wake suppuration, abscess formation, and general septic infection; 
on the other hand and later, stricture formation and all its attendant 
difficulties. 

Rupture of the urethra, therefore, is always a serious injury, and in 
order that its dangers may be obviated, promptness of recognition 
and intervention is imperative. 

The symptoms of injury to the urethra are definite though varying 
in degree and are: retention of urine, hemorrhage from the urethra, 
and perineal tumor. 

These symptoms, together with the history of the case, readily 
make the diagnosis, but only by a careful study of each, recalling at 
the same time the anatomy of the urethra, may one decide upon the 
location of the injury. 

(a) Retention of urine accompanies in some degree all traumatic 
Tuptures, though one should not make a diagnosis from this symp- 
tom alone for retention may follow a mere contusion — an interstitial 
rupture, without any solution of the continuity of the canal and with- 
out obstruction. It has its origin in •" shock," perhaps, with tem- 
porary paralysis of the bladder musculature. In such a case, there 
is gradual development of a perineal tumor from the contusion, but, 

I on the other hand, the bladder slowly fills and rises out of the pelvis. 
In a few hours, the urine begins to dribble; a little later micturition 
becomes voluntary though painful, and gradually the function is re- 
stored to the normal. In actual rupture, the retention is complete 
and continuous. 

(b) Hemorrhage from the urethra is indicative of rupture, but its 
amount in nowise points to the degree of urethral destruction. No 
inference may be drawn from it as to the severity of the lesion. In 
fact, the slighter the hemorrhage, the worse the outlook if the other 
symptoms are aggravated. For instance, if the mucous membrane 
alone is torn, the hemorrhage is immediate, perhaps voluminous, and 

iyet the lesion is of minor importance. On the other hand, if the 
rupture is complete, the blood pours out into the lacerated tissues of 



688 RUPTURE OF THE URETHRA 

the perineum, and only a few drops may find their way through the 
occluded canal. Therefore, one must never conclude that because 
the hemorrhage from the meatus is slight, the injury is slight. 

(c) Perineal Tumor. — There is always swelling in some degree fol- 
lowing contusions of the perineum whether the urethra is injured or 
not. The perineal and scrotal tissues are ecchymosed and the 
scrotum especially is likely to be engorged with exudates. If the 
urethra is ruptured the bladder empties itself into the bruised perineal 
tissues, the ecchymosis rapidly becomes an edema, gradually thicken- 
ing and expanding. It is at first an ovoid swelling in the middle of 
the perineum, but gradually spreads until the scrotum, the pelvis, and 
finally the abdominal walls are infiltrated, thickened or edematous to 
a marked degree. But do not forget that the absence of a perineal 
tumor does not always mean that the injury is slight. If the rupture 
is situated behind the anterior layer of the triangular ligament and if 
this is not torn, the transudates cannot reach the perineum, for this 
tendinous band limits the forward movement of the urine; and so, 
taking the direction of least resistance, it percolates through the cellu- 
lar tissues of the pelvic cavity and passes up along the side of the 
bladder to the abdominal wall. Since, however, the anterior layer of 
the triangular ligament is nearly always torn to some extent, peri- 
neal swelling is nearly always present. Slight swelling will give no 
feeling of security that the injury is slight. It is obviously essential 
that one must have clearly in mind the anatomy of the urethra. 

THE ANATOMY OF THE URETHRA 

Stretched across the anterior segment of the pelvic outlet, between 
the rami of the pubes, is the triangular ligament, dense and fibrous, 
and arranged in two layers, separated by a 3^-inch space. In 
contact with the deep or pelvic surface of the triangular ligament, is 
the apex of the prostate gland. In contact with the superficial or peri- 
neal surface is the bulb of the urethra, the knobbed posterior ex- 
tremity of the corpus spongiosum. The urethra traverses the pros- 
tate, perforates and bridges the space between the two layers of the 
triangular ligament and then tunnels the bulb, runs the length of the 
corpus spongiosum, and emerges at the glans penis, the anterior 



TREATMENT OF CONTUSION 

knobbed extremity of the corpus spongiosum. The part of the ure- 
thra anterior to the triangular ligament consists, then, of two por- 
tions, the penile and bulbous; the deep urethra of two, the prostatic 
and membranous, which later is the part which bridges the 1 9- 
inch space between the two layers of the triangular ligament. The 
clinical manifestations of rupture depend upon whether the bulb- 
ous or membranous portion is involved and in a minor degree upon 
whether the rupture is partial or complete. (See Fig. 546.) 

CONTUSION OP THE BULBOUS PORTION 

Injury to the bulbous portion is by far the more frequent: it is the 
form which the practitioner will nearly always find. It remains for 
him to decide whether the injury is a contusion or rupture, for the 
prognosis and treatment are quite different in the two degrees of 
injury. If the case is one of contusion, it is likely the hemorrhage 
was abundant; the patient complains of pain and inability to pass 
water; there is no perineal tumor though the tissues may be much 
bruised. After a few hours he begins to pass water after painful 
effort. The urethral bleeding may persist, but the bladder keeps well 
emptied. 

Treatment. — The treatment is very simple. Keep the patient 
quiet, relieve the pain if necessary with small doses of morphine, and 
give some urinary antiseptic such as urotropin. 

Do not pass a catheter. Why should you? The bladder empties 
itself; there is no perineal infiltration; and to do so would only 
increase the risk of infection. The normal micturition will return in 
!a few days in the cases of mild contusion, and perhaps in a week the 
patient will be well. If, however, in such a case, after a few days mic- 
turition should become more painful and finally impossible, due to 
urethral swelling or spasm, catheterization is indicated. Try a large, 
soft, aseptic catheter first; try to carry it gently along the upper 
wall of the urethra. You may fail and be forced to fall back on a 
:atheter of small size, but in no case must violence be used or the 
attempts prolonged. The catheter may be left in if the introduction 
difficult, but it mu.-t be kept under constant surveillance, and at 
the first appearance of a perineal tumor, indicative of infiltration. 

44 



690 RUPTURE OF THE URETHRA 

operation is imperative. If a catheter of small size has to be em- 
ployed, it may not fill the urethra and there may be some dribbling of 
urine, which favors infection. In such a case the catheter remaining 
in the bladder may keep it empty by siphonage. 

Contusion, with the formation of a large hematoma in the peri- 
neum, might simulate rupture, but the presence of a distended blad- 
der demonstrates that the perineal tumor is not infiltrated urine. 
In such a case again, an attempt should be made to pass a catheter if 
the urine does not begin to flow after three or four hours. If suc- 
cessful, the size of catheter may be increased from day to day. 

It must be borne in mind in making the first attempt that too per- 
sistent effort may result in rupture of the already contused urethra, 
or insure infection. 

In case of failure, you may follow the recommendation of Lejars, 
and proceed to drain the bladder by suprapubic puncture and it may 
be, after a day or two when the swelling has subsided, a catheter can 
be passed and drainage secured in that manner as before, but hold 
yourself ready to operate at the first sign of infiltration. 

This line of treatment can only be recommended to those who are 
sure they can distinguish between hematoma following contusion and 
infiltration following rupture. In case of doubt, always treat the 
case as one of rupture. 

RUPTURE OP THE BULBOUS PORTION 

Urethral hemorrhage, rapidly increasing perineal tumor obviously 
due to infiltrating urine, and retention of urine following injury point 
at once to some destruction of the urethral wall. 

There is no use of wasting time attempting to pass a catheter; 
prepare at once for an external urethrotomy. Even if you succeed 
in passing a catheter, it will not prevent extravasation in the end, as 
Reginald Harrison and others have pointed out. Nor is there need 
to wait for additional symptoms. The indications for operation are 
unmistakable. Delay merely exposes the patient to all the risks of 
infection. The end in view is to furnish a free outlet for the urine 
and if possible to repair the ruptured canal. 



OPERATIVE TECHNIC 



69I 



Operation for External Urethrotomy. — Provide for the operation 
soft rubber catheters of various sizes; a grooved staff or steel sound; 
small, curved needles, silk No. o, and three or four sizes of catgut. 

General anesthesia is indispensable. Place the patient in the 
lithotomy position with the perineum exposed to a good light. The 
entire field must be disinfected with extreme care. 

As soon as the patient is anesthetized, an effort may be made to 
pass a catheter, and, if successful, the operation will be greatly facili- 
tated. Otherwise pass the guide as deeply as possible without using 




■■ ;f >^> 



^ 



Fig. 523. — Incision exposing the bulb of the urethra. (Duval.) 



force, and let it be held in position by an assistant who also supports 
the scrotum. 

The median incision extends from the base of the scrotum to within 
an inch of the anus. Divide the skin and fascia, when you may 
reach an area filled with clots and lacerated tissues, the site of the 
bulb and its muscular coverings (Fig. 523). You may not be able 
to recognize the bulb if the destruction has been great, but after 
wiping out the clots and debris, a cavity is exposed (Fig. 524). Ex- 
pose the point of the guide, and you have thus located the opening 



t>0 



RUPTURE OF THE URETHRA 



into the distal half of the urethra. Determine the nature of the 
urethral tear, whether partial or complete. The subsequent pro- 
cedure will depend largely upon the type of injury present. 

(a) If you find rupture of the lower wall only, the remnant of the 
upper wall, a mere band perhaps, will be a great help in the next 
step, which is to locate the orifice of the urethra on the farther side 
of the tear. The search for this opening must be patient and minute. 
Let the point of a probe or grooved director follow the remnant of the 




Fig. 524. — The muscular and erectile tissue of the bulb divided, exposing 

the urethra. (Duval.) 



upper wall backward and it may haply engage in the orifice and pass 
on into the bladder; if it does not, every bit of the mangled tissue 
must be examined. 

Another maneuver may be tried: if you have a soft-rubber catheter 
in the urethra, pull it down into the wound and endeavor to engage 
its point in the hidden orifice. Once the orifice is found and the 
catheter carried into the bladder, try to suture the urethral wound 
over the catheter. Place lateral sutures of fine silk or catgut, begin- 
ning at the upper wall and suturing toward the lower where the 



OPERATIVE TECH NIC 



693 



separation is greatest. If possible, pass the suture through the outer 
coats only. 

(b) If the rupture is complete and the two ends are widely 
separated, the difficulties are aggravated. There is no trace of the 
upper wall left to assist in the slightest degree in locating the orifice 
of the proximal segment of the urethra. 

" With the point of the grooved director, every small orifice, every 




| Fig. 525. — Soft catheter passed into the bladder after repair of the upper wall. (Duval.) 



I depression, every fringed tubercle must be examined in the hope that 
, it represents the opening." 

If you find something which looks like mucosa and the lumen of 
I the canal, introduce the point of your catheter and if it is in the right 
] track, it will glide into the bladder. 

"A good light, patience, perseverance, and an accurate knowledge 
j of the anatomical relations of the injured parts often lead to success 
in the most difficult cases." (Senn's Practical Surgery.) 



694 



RUPTURE OF THE URETHRA 






Pressure on the bladder may sometimes help by forcing a drop or 
two of urine through and thus exposing the urethral opening. Some- 
times bleeding from the ruptured artery of the bulb will serve as a 
guide to the hidden opening. 

The incision may be extended backward with a view to exposing 
the canal, but this is often unsatisfactory and care must be taken not 
to wound the anal sphincter. 

If, by any of these means, the orifice is finally located and the 
catheter passed into the bladder, it remains to adjust and suture the 




Fig. 526. — Repair of the muscular layers. (Duval.) 

divided ends. The ideal way consists in making an end-to-end 
anastomosis, passing the sutures through the outer coats only. 
Occasionally you will be satisfied if, by passing sutures through all 
the coats, you can approximate, in some degree, the two ends, favor- 
ing by that much the ultimate restoration of the canal and minimiz- 
ing the stricture formation (Fig. 525). 

"In twenty-nine reported cases of rupture of the urethra treated 
by immediate suture, all are announced as successful. These results 
are astonishing and commend repetition." (Bryant's Operative 
Surgery.) 



SUPRAPUBIC CYSTOTOMY 695 

After suture of the urethral tear, the perineal wound may be short- 
ened a little by one or two sutures, but ample space must be left for 
drainage. A wound unnecessarily large is much less dangerous than 
one too small (Fig. 526). 

Pack the wound with iodoform gauze. The catheter should be 
left in the bladder for three to four days, when it is removed and a 
steel sound passed thereafter every two or three days until repair is 
complete. 

(c) What are you to do in case patient search fails to locate the 
bladder end of the torn canal and you are unable, therefore, to pass 
the catheter into the bladder and to suture? Two procedures are 
recommended: 

(1) Pack the wound with iodoform gauze and empty the bladder 
as necessary by suprapubic puncture. Perhaps at a later examina- 
tion the opening may be found, or, as will nearly always happen, the 
bladder is sufficiently drained after a day or two, through the perineal 
wound. 

(2) Do a suprapubic cystotomy and " retrograde catheterization." 
Where the general condition of the patient and other circumstances 
permit, this procedure is the better, since it assures drainage 
and facilitates primary repair by definitely locating the bladder 
end of the torn urethra in the perineal wound. It is necessarily 
a delicate operation and should not be undertaken by the wholly 
inexperienced. 

To perform suprapubic cystotomy and retrograde catheterization, 
begin by carefully disinfecting the abdominal wall. Make an in- 
cision 2% inches long in the middle line, beginning at the pubes 
and cutting through the skin and subcutaneous tissues and the 
fascias. Retract the lips of the wound widely. You may not be 
able to distinguish the peritoneal covering of the bladder, for it may 
be above the upper level of the wound. In any event, it must be 
pushed up out of the way. Next locate the bladder, which is easily 
felt if it is distended; but if it is not, follow the posterior surface of 
the pubes. 

Transfix the anterior wall by a suture on each side of the proposed 
line of incision, and lift the bladder upward to the abdominal wound 
and open it by a free incision. A small incision is a nuisance, while 



bgb RUPTURE OF THE URETHRA 

a large incision renders the subsequent steps easier and is easily 
sutured at the end of the operation. 

With the bladder opened, the next step is to pass the catheter. 
If possible locate the urethral orifice in the bladder and pass the 
catheter by sight, but you will usually have to depend upon touch 
for this Drocedure. 

Introduce the left index and middle fingers into the bladder and 
touch the base. Now draw the fingers forward in the middle line 
and the neck of the bladder will be recognized by its relation to the 
prostate, and the urethral opening feels like a pimple on the base of 
the gland. The catheter is now slipped along the finger resting on 
the orifice. Once engaged, it is pushed on through the urethra until 
its point emerges in the perineal wound. Couple it onto the soft 
catheter in the anterior part of the urethra and retract it through 
the abdominal wound, and by this means the catheter in front is 
drawn into place and should be left in the bladder after the urethr 
and perineal wounds are sutured, as before described. 

We must now provide for the drainage of the bladder through 
the suprapubic wound. Employ a medium-sized catheter and let it 
reach almost to the bottom of the bladder and anchor it in place 
with a safety-pin. Suture the bladder wound tightly about the 
tube. Repair the abdominal wall, leaving enough room for light 
gauze packing about the tube. 

"Many elaborate methods of suprapubic drainage are described, 
but this tube connected to a long rubber tube by means of a glass 
coupler and terminating beneath the bed in a bottle filled one-quarter 
full of bichloride solution, will meet all the requirements of the case." 
(Taylor, G. U. and Venereal Disease.) 

The tube may be replaced by a smaller one after two or three days. 
As soon as possible, the wound is allowed to fill up by granulation 
and the drain is entirely removed. 

RUPTURE OF THE MEMBRANOUS URETHRA 

This accident is rare except in connection with fractures of the 
pelvis. Under any circumstances, it is even more dangerous than 
rupture in front of the triangular ligament, for the extra vasated 



a 



RUPTURE OF THE PENDULOUS URETHRA 697 

urine may easily spread up into the pelvic cavity and induce cellulitis 
and general infection. Examination per rectum will often reveal the 
edema, no signs of which appear in the perineum. 

Nothing but free incision and drainage through the perineum is 
of any use. 

Finally the pendulous portion of the urethra may be ruptured, 
sometimes in coitus, and the hemorrhage may be quite alarming to 
the patient; there may also be retention of urine. Usually catheteri- 
zation will be sufficient. 



CHAPTER XX 

ACUTE RETENTION, CATHETERIZATION, SUPRAPUBIC 
PUNCTURE, CYSTOTOMY, URINARY INFILTRATION 

Every acute retention of urine demands immediate relief. It 
must be relieved not only on account of pain and discomfort, but 
more especially to avoid damage to the bladder or urethra and the 
evil effects of sepsis. This rule applies equally to the cases due to 
temporary insufficiency of the bladder musculature and to those due 
to urethral obstructions. 

Urethral obstruction may assume various forms. In general prac- 
tice, it will usually originate in one of three ways : spasm of the ure- 
thra, enlargement of the prostate gland, or stricture. Very many 
more times than we suspect in those cases regarded as simple reten- 
tion from spasm, the real and predisposing cause is organic. In every 
case before instituting measures for relief, it is wise to make minute 
inquiry into the patient's history with respect to this function. At 
least one should be suspicious of the presence of stricture and on his 
guard. 

It is true that, in a particular case, certain circumstances tend to 
make one or the other of the causes of retention the more probable. 
Thus, if the patient, is in a febrile attack or has suffered some slight 
trauma of the urethra or has undergone an operation on a region ad- 
joining the urinary tract, one thinks of retention from urethral spasm. 
If the patient is known to have a sexual history, has been a votary at 
the shrine of Bacchus and Venus, the logical inference is organic stric- 
ture. If the afflicted one is elderly, one thinks of enlarged prostate, 
though mere age does not rule out other causes of obstruction. One 
may be past the hey-day of life and yet strictured, paying late the 
price of pleasures long since fled. 

But after all, whether the predisposing cause is temporary or per- 
manent, the actual exciting cause is usually congestion. This is a 

698 



ACUTE RETENTION 



699 



practical point constantly to be borne in mind, for it is congestion 
which makes urethral instrumentation potent to produce trouble, and 
which makes strict asepsis an absolute necessity. 

CATHETERIZATION 

The first measure of relief to be tried in actual retention, if opium 
and a prolonged warm bath are not practical, is catheterization. To 
meet the possible indications every practitioner should be armed. 
A certain equipment is indispensable. 

A cylindrical metal case capped at one end is most convenient in 
which to keep and carry these instruments. The most essential are 




CX.'E.WYZ.icSOWS 



Fig. 527. — Conical. 



Fig. 528. — Olivary. 

Fig. 529. — Cylindrical. 
{Stewart.) 



Fig. 530. — Elbowed flexible catheter. 




Fig. 531. — Mercier double elbowed flexible catheter. 

soft-rubber catheters of various sizes, flexible bougies with olivary 
and conical tips, gum catheters with single and double elbows or 
armed with stylets, filiform bougies (Figs. 527, 528, 529, 530, 531). 

Sterilization of these instruments may be a problem, except as to 
the rubber catheters, which may without injury be disinfected by 
boiling. The other instruments are best sterilized by formaldehyde 
vapor and should be prepared before leaving the office and carried 
wrapped in sterile cloths. 

Without the special sterilizer, one must boil these instruments, 
risking eventual injury. They may be fairly well cleaned by rubbing 
with an antiseptic ointment or by immersion in a 1-20 carbolic or 



700 CATHETERIZATION 

i-iooo bichloride solution. Previous to its introduction, anoint the 
catheter with sterile vaseline or similar lubricant. 

Position of Patient. — The patient should lie upon a table high 
enough that the operator does not need to stoop. The pelvis should 
be elevated and the thighs flexed and abducted. Begin by thor- 
oughly cleansing the field; cleanse the penis, the foreskin on both sides, 
the glans and the meatus, wiping each part with a separate com- 
press. If possible, irrigate the urethra with boric acid or normal salt 
solution. 

Whatever condition may be suspected in an unexplored urethra, 
make the first attempt at relief with a large catheter, seventeen or 
eighteen French, which, as is well known, excites less resistance than 
one of smaller size. Standing at the patient's left side, hold the penis 
between the finger and thumb of the left hand, elongating it, while 
managing the catheter with the right. Usually it is best to hold the 
instrument parallel with the groin as its beak enters the meatus, 
gradually bringing the handle to the middle line of the abdomen as 
the instrument penetrates. As the catheter progresses it may be 
helped along by giving it a slightly boring motion. Proceeding thus 
gently but steadily, always avoiding force, the bladder may be 
reached. If not, a smaller catheter is to be tried, and so on until one 
is found that will enter. If all these efforts fail and it becomes 
evident that a practically impermeable stricture is present, resort must 
be had to filiform bougies, which may be bent into various shapes, 
bayonet shape, or corkscrew form, and kept so by a thick collodion 
coating. 

A filiform bougie is passed until it engages, and then various back 
and forth, side to side, movements are imparted with the hope of 
finding a passageway through the scar tissue. The point may en- 
gage in lucunae or in false passages, and often it is useful to leave the 
bougie in situ. A half-dozen may be left in the urethra to occupy 
the false passages, until happily one finally passes into the urethral 
canal. Once a bougie is introduced into the bladder, it should be 
fastened and left until the second day, when often it may be replaced 
by a soft catheter or a larger bougie. In the meantime, the urine 
trickles past the stricture drop by drop, until, in a short time, the 
distention is relieved. 



CATHETERIZATION 



70I 



If the retention is known from the first to be due to stricture, the 
procedure may vary somewhat. Valentine and Townsend have 
defined the technic of emergency dilatation of urethral stricture 
in such a satisfactory manner (American Journal of Surgery, May, 
1907) that it is transposed for present use practically in its entirety. 

The hyperesthesia of the urethra, often so great an obstacle in 




Fig. 532. — Lubricating the urethra. (American Journal of Surgery.) 

'catheterization, is greatly relieved by filling the urethra with a 
I 33 per cent, solution of malaleuca sempervirens in sterile oil and 

holding it for three to five minutes. Local or general anesthesia is 

undesirable. 

No lubricant is used for filiforms, but the urethra is to be filled 
j with 10 per cent, suspension of iodoform in glycerin, injecting with a 

sterile glass syringe of 1 -ounce capacity. The penis is held in the 



702 



CATHETERIZATION 



left hand, the index finger and thumb pressing the meatus open. 
The tip of the syringe is inserted and the contents slowly injected 
until it can be felt that the urethra is full (Fig. 532). When the in- 
jection is complete the finger and thumb compress the meatus to 
prevent the escape of any of the fluid to make the fingers or penis 
slippery. 

The filiform is to be inserted. A straight bougie, 5 French, is in- 




Fig. 533. — Inserting a filiform. {American Journal oj Surgery.) 



serted as far as it will go without force (Fig. 533). A smaller one is 
then passed alongside the first and the procedure continued with 
smaller straight bougies until a No. 1 has been inserted as far as 
possible. This is then left in place and from three to six more intro- 
duced, each one being left at the point of arrest. 

When as many filiforms as will pass the meatus without stretching 
it are thus inserted, the one first introduced may be urged slightly for- 
ward. If its point is free but cannot progress, it may be withdrawn 



CATHETERIZATION 



703 



and an angular filiform inserted in its place. It should be gently 
rotated to the right and left as obstruction is met with. If it makes 
no progress, it may be left in place and another of the straight fili- 
forms withdrawn to be replaced by a bayonet filiform. The bayonet 
filiform is to be pressed forward and then withdrawn slightly and 
again advanced in a different direction, hoping to find the lumen. If 
this fails, the corkscrew filiform is to be tried, removing some of the 
straight filiforms if necessary to have more room. 




Fig. 534. — Kollmann filiform guides. (American Journal of Surgery.) 

When the corkscrew's tip reaches the face of the stricture, it is to 
be rotated, trying first the right spiral and then the left. If the sec- 
ond one fails, leave it in place and try each of the straight ones again, 
pushing it gently forward, and if it fails to enter, withdrawing it. 
After all the straight ones are tested and removed, try the corkscrew 
that remains in the urethra and then the one tried first. 

If all these maneuvers have failed, an attempt may be. made with 




Fig. 535. — Valentine-Townsend filiform carrier. (American Journal of Surgery.) 



the Kollmann guide (Fig. 534). A straight or curved guide is to be 
used, depending upon the location of the stricture. It is passed up 
to, and pressed firmly against the face of the stricture, while a straight 
filiform is introduced and lightly pushed up against the stricture, 
changing the position of the guide from time to time. If this attempt 
with the Kollmann guide fails, a metal sound as large as will pass to 
the stricture by its own weight is introduced and held against the 



704 



C ATHE TERIZ ATION 



stricture for five minutes or more and quickly withdrawn and the 
urethra refilled with the iodoform-glycerin solution and all the ma- 
neuvers with the filiforms repeated, often with the result that the 
first inserted will traverse the stricture and enter the bladder smoothly. 
The urethroscope is sometimes useful in locating the orifice, but 
even then the filiform may be difficult to enter, manifesting the 
"perversity of things inanimate;" although the shortest urethroscope 

tube be used, the filiform will cling to its 
sides or will sway to and fro, touching 
every point of the exposed region except 
the orifice. Under the circumstances, 
the Valentine-Townsend filiform carrier 
(Fig. 535) is to be recommended and its 
use is thus described: 

After the urethroscopic tube is inserted, 
the urethral mucosa dried, and the light 
in place, the carrier, armed with a fili- 
form, is inserted. The lowermost ring 
containing the filiform's tip is pressed 
against the face of the stricture at the 
point where its lumen is visible. Once 
fixed by slight pressure, the filiform is 
very slowly projected into the exposed 
lumen. If it fails to traverse the stric- 
ture, an angular and then a corkscrew 
filiform are tried as before described. 

Whenever a filiform reaches the bladder, 
the fact is announced by the ease with 
which the instrument can be moved to 
and fro, and by the increased desire to urinate when the filiform 
touches the bladder walls. A few drops of urine trickle by the filiform. 
The filiform must be fastened in place: No effort must be made at 
this time to pass a larger instrument. Valentine and Townsend 
recommend the following method of holding the filiform in place: 

Two pieces of sterile cord 6 inches long are used, one tied about 
the bougie in front of the meatus so that the knot corresponds to the 
dorsum of the penis, and the other tied so that the knot corresponds 




Fig. 536. — Cord attached to 
instrument in urethra. (A merican 
Journal of Surgery.) 



CATHETERIZATION 



70S 



to the insertion of the frenum (Fig. 536). "Take the cords project- 
ing from one side of the glans and pass them through one of the four 
holes of a common pearl shirt button, draw the button upon the two 
joined cords until it rests exactly at the post, coronary sulcus. Tie 
a knot in each cord at that point to fasten the button in place" (Fig. 
537). Proceed in the same manner on the opposite side. 




Fig. 537. — Attaching button to cord. (American Journal of Surgery.) 



A cord passing over the penis connects the two buttons; another 
passing under the penis is threaded onto the two buttons and tied, 
care being taken not to disturb the position of the two buttons (Fig. 
538). Finally a cord 12 inches long is fastened into the remain- 
ing hole of each button, and carried backward to be attached to the 
pubic hairs after Guyon's method (Fig. 539). 




Fig. 538. — Uniting cords attached to button, lateral holes. (American Journal of Surgery.) 

"The penis is then to be dressed, covering it with an aseptic gar- 
ment. 

L" Three layers of sterile gauze 10 inches square are folded to form 
triangle. This is passed under the penis with the base toward the 
scrotal angle. The apex is tied to the instrument at its projection 
45 



706 



CATHETERIZATION 



at of 



from the meatus. The two angles at the base are carried in front 
the penis, one above the other, and their points are attached to the 
pubic hairs by the extremities of the cords left after tying in the 
instrument" (Fig. 540). 

A pad of cotton should cover the genitals, and the whole be covered 
by a towel, to be changed as often as soiled. 

" While it is better that the patient with a filiform fixed in his 





Fig. 539. — Cords attached to pubic hairs. 
(American Journal of Surgery.) 



Fig. 540. — Penis dressed. (American 
Journal of Surgery.) 



bladder remains in bed, there are circumstances in which it is impera- 
tive that he be allowed to go about and attend to his occupation. 
Protected against the dangers of retention as above, this is permissi- 
ble unless he be engaged at hard labor." 

In the case of retention due to enlarged prostate, the mode of proced- 
ure is quite different if the primary effort at passing a soft catheter 
fails. 



SUPRAPUBIC PUNCTURE 707 

The prostatic catheter with long curve may be tried, passing it as 
deeply as possible before depressing the handle between the thighs, 
pulling the penis upward, elongating it to facilitate the movement of 
the sound. Once the point is in the perineal region, the handle is to 
be depressed rapidly, at the same time pushing the sound on, hoping 
in this manner to carry it over the prostatic projection. No force 
must be employed. Often the Mercier elbowed or double-elbowed 
catheter will surmount the difficulty (see Figs. 453 and 454). 

Sometimes a large gum elastic catheter armed with a stylet may be 
useful. The catheter is introduced to the obstruction, the stylet 
slightly withdrawn, which serves to tilt the end of the catheter and 
permits it to be pushed on into the bladder. 

In these cases of chronic enlargement of the prostrate, frequent 
catheterization may be required. As Stewart (Surgery, page 653) 
says, if it becomes difficult, if there is marked irritability of the 
bladder, if the residual urine steadily increases in quantity, or if 
there is stone or persistent cystitis, catheterization must be aban- 
doned and operation advised. 

PUNCTURE OF THE BLADDER 

When catheterization has failed and relief is imperative, supra- 
pubic puncture is the next resort. It is in nowise dangerous if aseptic, 
except possibly in those long strictured or long troubled with enlarged 
prostate, when the peritoneal covering of the bladder may approach 
the pubes. 

Begin with a careful disinfection. Shave and scrub the abdomen 
and pubes. Select for puncture the point immediately above the 
pubes in the middle line exactly. The instrument, which may be an 
aspirator or simply a trocar, is to be entered at the point indicated, 
without fear of going too deep, and pushed backward and slightly 
downward until resistance ceases. Withdraw the stylet and the 
urine follows in a steady stream. A rubber tube may be attached 
to the trocar. The bladder should not be emptied rapidly, but 
slowly, interrupting the flow from time to time. When the bladder 
is emptied, the trocar is to be withdrawn with a rapid movement 



708 CYSTOTOMY 






and the opening covered with a sterile compress, or, if quite small, 
with collodion. 

Aseptic puncture may be practised once or twice a day for a num- 
ber of days without serious consequences, and at the end of this time 
the congestion of the urethra may be relieved and the urinary func- 
tion restored. If, however, at this time the urethral obstruction 
cannot be overcome, then one must proceed to establish permanent 
drainage. 

Permanent drainage is indicated from the first if distance precludes 
two or three daily visits, for there is no use to relieve the patient by 
puncture and then leave him to the danger and pain of a new re- 
tention, certain to occur. 

Again, if the urethra has been lacerated by rough attempts at 
catheterization, and if to the symptoms of retention are added those 
of sepsis and the signs of beginning infiltration, it is imperative, to 
establish permanent drainage of the bladder. 

Under these circumstances the puncture may be performed with a 
large trocar, and after the bladder is emptied a catheter can be passed 
through the cannula into the bladder as far as possible and the can- 
nula gently withdrawn. 

The catheter must be fixed in position, and this can readily be done 
by threads attached to the skin with collodion. To the catheter a 
long rubber tube should be attached, ending below in a vessel con- 
taining an antiseptic solution. By this means a siphonage is estab- 
lished and the bladder kept constantly emptied and prevesical in- 
filtration avoided. 

CYSTOTOMY 

Permanent drainage through the suprapubic puncture is often 
alone available, though by no means ideal. Whenever possible, the 
bladder is to be opened formally and the drainage established by 
that means, nor is the operation beyond the skill of the general 
practitioner. 

No special equipment is necessary: scalpel, scissors, artery forceps, 
dissecting forceps, small curved needles. Local anesthesia may be 
employed in case of necessity, though, of course, general anesthesia 
is desirable. The region is to be carefully prepared. 






CYSTOTOMY 



709 



Operation. — Begin with an incision 3 inches long commencing 
at the pubes and extending upward in the middle line (Fig. 541). 
Divide the skin and fat down to the aponeurosis. Divide the aponeu- 
rosis and expose the prevesical fat (Figs. 542-543). Draw this fatty 
tissue upward, and with it the vesical peritoneum, exposing the blad- 
der. The bladder appears dark and globular, marked by large veins. 







A 


K\ 


mM 


^Hi 1 


ll 


Wm] 




j 




asv] 


\ 






1 / 


V V 


vf i 




f <#•/<: 



Fig. 541. — Cystotomy. Primary incision exposing linea alba. 



In fat subjects it may seem deeply situated in spite of its distention, 
but one need nor fear to get into something else. 

It is helpful in controlling the bladder and, later on in suturing, 
next to pass a suture on either side of the proposed line of incision, 
The sutures should^ pass through only the superficial tissues and be 
parallel to the bladder incision. Next proceed to open the bladder 



710 



CYSTOTOMY 



in the middle line, making the puncture at the level of the pubes with 
the cutting edge of the bistoury turned upward, prolonging the in- 
cision from a half-inch to an inch. If the sutures have not been 
passed, catch up the edges of the vesical wound with forceps while 
the urine flows out. 




Fig. 542. — Partial incision of the deep layer of the sheath of the recti, exposing 

the prevesical fat. 



The bleeding, often considerable at first, is not a matter for con- 
cern and ceases spontaneously as the emptied bladder contracts. 

When the bladder is emptied, douche it thoroughly with warm 
sterile water and explore its cavity for possible calculi. 

It remains to suture the edges of the bladder wound to those of 
the skin wound (Fig. 544). If the traction sutures mentioned were 
passed, they may now be used to draw the bladder up into close con 






OPERATIVE TECHNIC 



711 



tact with the abdominal wall, passing them through the entire thick- 
ness, and tying them on the outside. 

The mucous membrane is now brought in contact with the skin 
and sutured with catgut (Fig. 545). It the condition of the vesical 
walls does not permit the careful coaptation described, then four or 
five sutures may be employed, passing through all the layers of the 




Fig. 543. — Cystotomy. Recti separated, prevesical fat exposed. 



bladder and abdominal walls, bringing them into contact. In this 
case a catheter must be introduced and siphonage instituted. In 
the first case, where the skin and mucosa are exactly coapted, it is 
not necessary to leave a catheter in the bladder. The skin wound 
is, of course, sutured above and gauze should be packed around the 
catheter. The after-history will depend upon the condition present, 
but the ultimate aim will be to restore the urethral functions. 



712 



INFILTRATION OP URINE 



INFILTRATION OF URINE 

Sometimes it happens that following a retention, partial or com- 
plete, the urethra gives way and the urine percolates through the 
adjoining tissues. Under these circumstances, the urine is nearly 
always septic, the patient debilitated, and the conditions are thus ripe 
for a rapid fatality. 



F 




Fig. 544. — Cystotomy, 



Bladder fixed to the abdominal wall, sutures passing through the 
recti; bladder opened. 



Shortly after the rupture of the urethral wall, the perineal tissues 
become edematous, and the scrotum and penis markedly swollen. 
The infiltration soon involves the public and hypogastric region. 

The symptoms are those of sepsis: rigors, fever, pulse rapid and 
weak, tongue dry, anxious facies, profound depression generally, 
the symptoms depending in degree upon the duration of the accident, 



OPERATIVE TECHNIC 



713 




Fig. 545. — Cystotomy. Sutures connecting the edges of the bladder wound and the skin. 

Repair of the abdominal wall. 



714 



INFILTRATION OF URINE 






the rapidity of the urine's spread and its septicity. Diffuse phleg- 
mon and gangrene may rapidly ensue. 

The rupture usually occurs in front of the triangular ligament — 
the deep perineal fascia — and so the urine moves forward toward 
the scrotum and pubes, which is the direction of least resistance 
(Fig. 546). 

The treatment has two ends in view: to relieve the burdened tissues 




Fig. 546. — Rupture of the urethra in front of the deep perineal fascia and at point oi 
entrance to the bulb; showing the direction which the infiltrating urine may take into penis 
and scrotum, perineum, and suprapubic region. (Veau after Hartmann.) 



and to open up a passage to the point of rupture. * To relieve the 
engorged tissues, a series of parallel incisions are to be made, extend- 
ing beyond the limits of apparent infiltration, for the deeper tissues 
are always more widely involved than the superficial. The incisions 
should be deep enough to reach the deep fascia. The bleeding is not 
likely to be serious, but any bleeding points may be caught up, and if 
the oozing still persists, the incisions may be packed with iodoform 
gauze. 



OPERATIVE TECHNIC 715 

To expose the urethra, put the patient in the lithotomy position 
and make an incision in the middle line, beginning at the base of the 
scrotum and terminating in front of the rectum (Fig. 547). There is 
no guide but the middle line, for the tissues, thickened and infiltrated, 
are unrecognizable. There is nothing to do but continue to cut, 
keeping in the middle tine, until rewarded by a spurt of urine. 

All the incisions are to be thoroughly irrigated with hot normal 
salt solution, the tissues gently squeezed and the dead tissues re- 
moved. A compress saturated with peroxide is next applied, this 
covered with absorbent cotton, and the whole retained by a T- 
bandage. 




Fig. 547. — Infiltration of urine: Perineal incision. (Veau.) 

Ordinarily drainage is unnecessary, for the open wounds give free 
escape to the fluids. Often one is surprised at the completeness of 
the repair. 

At first the urine flows out through the breach in the perineum, 
but after a little while a catheter may be passed and fastened in the 
bladder and the perineal wound allowed to heal. 

Lejars prefers the thermo-cautery to the bistoury, both because the 
hemorrhage is less and because it exercises a salutary action upon the 
tissues about to become gangrenous, but Veau believes the knife to 
be better, because it does not seal the mouths of interstitial drains. 

If, in the course of intervention, an abscess cavity extending up 



716 



INFILTRATION OF URINE 



toward the pubes is found, a drainage-tube must be passed as high as 
possible and fastened in position (Fig. 548). 

Sometimes it happens that the urethral rupture occurs behind the 
perineal fascia, and again taking the direction of least resistance, the 
urine may pass up along the side of the bladder to the deep layers of 
the abdominal wall; or it may pass downward and backward into the 




Fig. 548. — Infiltration of urine; placing drain. (Veau.) 



ischio-rectal fossae. This condition is all the more dangerous for 
the reason that the external manifestations are often delayed and in 
consequence the true condition is not suspected until too late. 

But whenever a zone of infiltration is found, wherever it may be, 
incise it and reach the urethra if possible. In the intra-pelvic in- 
filtrations it may be necessary to open and drain through the bladder. 



CHAPTER XXI 
SUTURE AND LIGATION OF ARTERIES 

In emergency surgery the suture of a divided vessel is occasionally 
applicable, but the doctor will usually prefer ligation, which will 
nearly always suffice. 

To suture a vessel, the blood current must be under temporary con- 
trol by means of a clamp protected with rubber, that the tunica in- 
terna may not be injured. 

The vessel wall is seized with a fine forceps. The silk sutures are 
placed one-sixteenth of an inch apart in a longitudinal wound, and 
only the outer coats are pierced. 

If an end-to-end anastomosis is required, three sutures are recom- 
mended by Murphy and the proximal end is invaginated in the distal, 
the sutures being passed first through the proximal and finally through 
the distal end from within outward and tied. 

The indications for arterial suture are as follows: 

i. Where ligation might bring about serious nutritional change. 

2. In all wounds of large vessels. 

3 . Operative wounds where a part of the vessel must be sacrificed. 

LIGATION OF ARTERIES 

It is a rule almost without exception that a divided artery must be 
exposed and both ends tied. 

Occasionally, in the case of secondary hemorrhage, it will be im- 
possible to secure the artery at the site of the hemorrhage and liga- 
tion at some point in the course of the artery above the lesion will 
then be imperative. So that though only rarely to be used in emer- 
gency surgery, yet the technic of special ligations should be kept in 
mind. 

General rules for all ligations may be formulated: 

i. Put the patient in some position best to expose the artery and its 
landmarks. 

717 



718 



SUTURE AND LIGATION OF ARTERIES 



2. Outline the course of the vessel, using aniline if necessary. 

3. Tie the vessel, but avoid tying near the origin of a large branch 
if possible. 

4. Let the middle of the skin incision correspond to the point of 
ligation and let its length depend upon the depth of the vessel. 

5. Leit the first incision include the skin and superficial fascia; the 
incision in each succeeding layer should be the same length as the 
first. 

6. Each structure must be identified as exposed. 



Fig. 549 




. — Ligation of an artery. A, opening the sheath; B, passing the ligature; C, tying 
the ligature. (Moullin.) . 



7. The sheath of the vessel is to be recognized by its position, pul- 
sation, and feel to the examining finger. 

8. The sheath is pinched up in the form of a cone, the base of 
which is incised with edge of the scalpel turned away from the vessel. 

9. Through this small opening the vessel is gently detached and 
the aneurism needle passed, beginning usually on the side in rela- 
tion with the vein and keeping it in close contact with the artery 

(Fig. 549)- 

10. After the needle is threaded and withdrawn, be assured that 
no other structures will be included in the ligature. 



LIGATION, COMMON CAROTID 



719 



11. Draw the knot tightly enough to occlude the lumen of the 
vessel, but not tightly enough to crush the inner coat. 

12. The subsequent treatment is that of an ordinary wound.- 

THE COMMON CAROTID (Fig. 550) 

The line of the artery corresponds to the anterior border of the ster- 
no-mastoid. 




Jfescen3efiS 

\ncni nerve 



a Carotid 
— \artery 

-Indjuyukr 
' , yetn 



hcrdkr cf Sterne 
Ma&fcid Muscle 



Fig. 550. — Ligation of the common carotid and facial arteries. {Moullin.) 

The incision should be 3 inches long in this line, the middle 
of the incision corresponding to the cricoid cartilage. Divide the 
skin, fascia, platysma; catch the bleeding veins, and divide the deep 
fascia along the sterno-mastoid, exposing the sheath upon which lies 
the descendens hypoglossi and the omo-hyoid. Just above the omo- 
hyoid, open the sheath from the inner side so as to avoid the internal 
jugular. Pass the needle from outside, also to avoid the internal 
jugular. 



720 SUTURE AND LIGATION OF ARTERIES 

EXTERNAL CAROTID 

Line. — -Continuation of the common carotid. 

Incision. — From the angle of the jaw to the thyroid cartilage, divid- 
ing the skin, fascia, and platysma. Ligate divided veins. 

Divide the deep fascia, exposing the sterno-mastoid, which is to be 
retracted. Locate the posterior belly of the digastric, the hypoglossal 
nerve, and the tip of the cornu of the hyoid. 

Expose the artery opposite the cornu; pass the ligature between the 
superior thyroid and the lingual arteries, avoiding the decendens hy- 
poglossi and the superior laryngeal nerve behind. The operation 
presupposes patience and a thorough knowledge of the anatomy. 
Through this same incision the superior thyroid, the lingual, the 
facial, the occipital, and the ascending pharyngeal arteries may be tied 
at their origin. 

LINGUAL (Beneath the Hyoglossus) 

Position. — -Place the patient on his back, turn the head to the oppo- 
site side and raise the chin (Fig. 551). 

Incision. — Curved, its center just over the greater cornu of the 
hyoid, extending from the symphysis of the chin to the angle of the 
jaw. Divide the skin, superficial fascia, platysma and deep fascia. 
Ligate the numerous veins which may be divided. Locate the lower 
border of the submaxillary gland and divide its fascia, thus exposing 
it, and lift it upward out of the way. 

Develop the mylo-hyoid; also the two bellies of the digastric and 
draw them down firmly. In the bottom of the wound is the hyo- 
glossus muscle. Identify the hypoglossal nerve with the lingual vein, 
which cross the hyoglossus. Incise the hyoglossus below, and paral- 
lel with, the hypoglossal nerve. Incising carefully, the artery bulges 
into the wound. Ligate the artery on the proximal side of the dorsalis 
linguae. 

SUBCLAVIAN (Third Portion) 

Position. — -Place the patient on his back with shoulders raised, 
head turned to opposite side, and angle of shoulder depressed 

(Fig. S5i). 



LIGATION, THE SUBCLAVIAN 



721 



Incision. — From the posterior border of the sterno-mastoid, over 
the clavicle, to the anterior border of the trapezius, drawing the skin 
down first to prevent wounding the external jugular. Relax the 
skin. The incision now lies 3^ inch above the clavicle. If more 
room is needed, partially divide the trapezius and sterno-mastoid. 
Divide the deep fascia and ligate veins. 

If the transversalis colli or the suprascapular arteries present, 
draw them to one side. 




Fig. SSI. — Ligation of the subclavian and lingual arteries. (Moullin.) 

Now identify the scalenus anticus muscle — a very important step, 
as it is the guide to the artery. Follow the external border of the 
muscle down to the first rib and there the pulsations of the artery 
will be felt. 

Identify the lowest cord of the brachial plexus, which, as well as 
the pleura and the subclavian vein, must be avoided in passing the 
ligature. 
46 



722 



SUTURE AND LIGATION OF ARTERIES 



THE AXILLARY (Third Portion) 

Position. — Patient supine, shoulders raised, arm at a right angle; 
operator between arm and body (Fig. 552). 

Incision. — -Along the line of junction of the middle and anterior 
third of the floor of the space. 

Divide the skin and fascia and expose the inner border of the 
coraco-brachialis. Draw the coraco-brachialis, the median and mus- 
culocutaneous nerves outward, the ulnar and internal cutaneous 
nerves inward. Avoid the basilic and axillary veins. 



ff?rae0-T, ra ,i%lal4ff muscle- 




ZTZiiar -^ 7l ^-' tfvt&neous nerve. 



Fig. 55 2o — Ligation of the axillary artery. (Moullin.) 

BRACHIAL (In the Middle of Arm) 
(See Operation for Exposure of Median Nerve.) 

BRACHIAL (Bend of Elbow) 
Position. — Limb extended and abducted, operator outside of arm 

(Fig- 553)- 

Incision. — Eollow the internal border of the bicipital tendon, the 
center of the incision corresponding to the bend of the elbow. Divide 
the skin and superficial fascia. Isolate the median basilic vein and 
the internal cutaneous nerve, retracting them inward. Next divide 
the deep and the bicipital fascia and beneath this latter lies the artery 
with its venae comites, the median nerve to the inner side. 

Do not neglect to repair the bicipital fascia. 



LIGATION, THE RADIAL 



723 



RADIAL (In the Upper Third of Forearm) 

Position. — Hand supine, surgeon to outside cutting downward 
(on the right) (Fig. 554). 

Incision. — ■ Along the inner border of the supinator longus for 3 
inches, dividing the skin and superficial fascia. Divide the deep fas- 
cia and separate the supinator longus and pronator radii teres. The 

Ten di nous Afi n euros is 
divided 




Fig. 553. — Ligation of the brachial at head of the elbow; the median basilic vein and internal 
cutaneous nerve drawn inward. {Moullin.) 



Supinator longus 




Fig. 554- — Ligation of the radial artery. In the floor of the wound is the pronator radii 
teres. The nerve lies some distance to the radial side. (Moullin.) 



he ^artery lies under the border of the supinator longus with the nerve to 
the outer side. 

RADIAL (At Wrist) 

:} \ Position. — The position is the same as before. 

Incision. — -The incision is along the supinator tendon. Avoid the 
radial vein and the superficialis volae artery. Divide the deep fascia 



724 



SUTURE AND LIGATION OF ARTERIES 



and separate the tendons of the supinator longus and flexor carpii 
radialis and between them lies the artery and its venae comites. 

ULNAR (At Wrist) 
(See Exposure of Ulnar Nerve, page 362.) 



Ztee/ifascia. 




Ccrd 



tSarCcriutS m/tisr/qfc 



Fig. 555. — Ligation of external iliac and femoral arteries. (Moullin.) 

SUPERFICIAL FEMORAL (At Apex of Scarpa's Triangle) 

Position.— Thigh slightly flexed, rotated externally, abducted 
surgeon to outer side (Fig. 555). 



LIGATION, THE FEMORAL 



725 



Incision. — Three inches long, with center over apex of triangle. 
Divide the skin and superficial fascia. Avoid the long saphenous 
vein. Divide the deep fascia and draw the sartorius outward; the 
adductor longus, inward. Avoid the internal cutaneous and the long 
saphenous nerves. The vein lies to the inner side and a little behind 
the artery. 

FEMORAL (In Hunter's Canal) 

Position. — -The position is the same as before. 

Incision. — -Three inches in the line of the artery in the middle 

third of the thigh. Divide the skin and superficial fascia. Avoid 

the internal cutaneous nerve and the long saphenous vein. Divide 



Tibialis anticus 




Extensor lonjjus 
digitoruut 

Fig. 556. — Ligation of the anterior tibial artery. The nerve lies to the 
fibular side. (Moullin.) 

the deep fascia, expose the sartorius and draw it inward. Incise the 
roof of the canal, but do not wound the long saphenous nerve which 
Is just beneath. Draw it inward and expose the sheath of the vessels. 

ANTERIOR TIBIAL (Middle Third) 

Position. — Thighs extended, leg turned inward and the foot ex- 
tended to indicate the position of the tibialis anticus muscle. 

Incision. — Four or five inches long in the line drawn from the head 
of the fibula to the middle of the front of the ankle-joint (Fig. 556). 
Expose the fascia. Divide it in the same line. By the sense of touch 
locate the septum between the tibialis anticus and extensor longus 
digitorum. Flex the foot to permit the separation of these muscles, 



726 



SUTURE AND LIGATION OF ARTERIES 



and follow the septum down to the artery. The nerve is to the front 
and outer side. Pass the ligature from without inward. 

ANTERIOR TIBIAL (Lower Third) 

Position, — Same as above. 

Incision, — Locate the tendon of the tibialis anticus; along its ex- 
ternal border divide the skin for 3 inches. Find the septum 
between the tibialis and the extensor proprius hallucis. In this 




Fig. 557. — Ligation of the posterior tibial artery. The gastrocnemius retracted; the 

soleus divided. (Moullin.) 

space lies the artery with the nerve to the front and outer side. Pass 
the ligature from without inward. 

DORSALIS PEDIS 

Position. — -Patient on back with foot extended and resting on heel. 

Incision. — -Two inches long beginning at the middle of the lower 
border of the annular ligament. Expose and separate the tendons of 
the extensor proprius hallucis and extensor longus digitorum; the 
artery is seen lying upon the tarsal ligaments. The nerve lies to the 
fibular side. Pass the ligature from without inward. 

POSTERIOR TIBIAL (Middle Third) 

Position. — -Patient on back; leg and thigh flexed; thigh rotated 
outward so that leg lies on its outer side (Fig. 557). 



LIGATION, POSTERIOR TIBIAL 



727 



Incision. — -Four inches long, along the line % inch behind the 
internal border of the tibia. Expose and divide the deep fascia. 
Expose and develop the inner border of the gastrocnemius; retract 
and thus expose the soleus attached to the inner border of the 
tibia. Divide the soleus vertically, and at the bottom of the 
wound is seen the yellow fibrous aponeurosis which covers the vesssel 
and deeper layer of muscles. Divide the aponeurosis about 1% 
inches from the internal border of the tibia and expose the artery. 
Draw the nerve to the outer side and pass the ligature from without 
inward. • 





Fig. 558. — Ligation of the posterior tibial behind the ankle. (Moullin.) 

POSTERIOR TIBIAL (At the Ankle) 

Position. — Turn the foot on its outer surface (Fig. 558). 

Incision. — Curved, 3 inches long, with center midway between 
malleolus and the inner tuberosity of the os calcis. Divide the fascia 
and the internal annular ligament cautiously. The artery is just be- 
neath the ligament. Separate the veins and pass the ligature from 
without inward. 



CHAPTER XXII 
SOME PRACTICAL AMPUTATIONS 

The primary aim of an amputation is to conserve the life or health 
of the patient; the secondary aim is to conserve, as much as possible, 
the function of the member. The first requires that as much as 
necessary be removed; the second, that no more than necessary be 
removed. The good surgeon will always adjust and harmonize 
these two principles and they will determine the time and technic of 
the particular operation. 

The time element is of especial concern in traumatism and gan- 
grene, for if the operation is done too early, too much may be re- 
moved in one case and too little in the other. In traumatism, tissue 
that at first sight seemed beyond remedy may survive; in gangrene, 
tissue that seemed viable may be left, only to necessitate another 
dangerous operation; so that following traumatism it is better not to 
operate until the limit of the devitalized tissue has been definitely 
determined; and in the case of gangrene, until the line of demarcation 
has definitely formed. 

The technic is principally concerned with conservation of function, 
and looks to the formation of a good stump. " A stump to be service- 
able, should be sound, unirritable, with good circulation and abun- 
dant leverage" (Bryant, Operative Surgery). To produce a stump 
with these qualities requires prevision of the flaps, particularly their 
shape, length, and vascularity. Upon their shape will depend the 
position which the cicatrix will take; upon their length, the com- 
fortable adjustment of skin and bone; upon their vascularity, the 
prompt repair, proper nutrition, and subsequent freedom from 
disease. 

The cicatrix should fall where it will be least subject to pressure 
and friction wherever that may be done without the sacrifice of useful 
tissues. In determining the position of the cicatrix, one must then 

728 



GENERAL TECHNIC 729 

consider the occupation of the patient and the possibility of an arti- 
ficial limb being worn. 

In the case of the leg, for example, the greatest tension might fall 
on the end of the stump, and a scar there be some source of annoy- 
ance; in the case of an arm, more pressure might fall on the side, from 
artificial appliances, and an end scar would therefore be more satis- 
factory. Nerves likely to be pinched up in the cicatrix should alway? 
be resected. The ends of severed tendons should likewise be re- 
sected, but not so high that their empty sheaths may be left to favor 
the lodgment of infection. 

That the stump may be sound and uniform in its outline, it is neces- 
sary that the different degrees of contractility of the various groups 
of divided muscles be known and their division accomplished accord- 
ingly so that finally their ends may occupy the same level. The 
bones must also be sawed squarely and care taken that the division 
is not completed by fracture. The periosteum must not be roughly 
handled. 

The technic is concerned also with the prevention of hemorrhage. 
This is best secured by first elevating the limb for several minutes 
and then applying an Esmarch tube above the site of the operation. 

After the section of the limb is completed and the large vessels se- 
cured and ligated, the tube must be removed and each bleeding point 
ligated separately. The tube has the disadvantage that there is 
nearly always a temporary vaso-motor paralysis due to the pressure, 
and on that account the oozing is considerable. 

The occasional surgeon will be called upon to do amputations 
under two entirely different circumstances, and his mode of proced- 
ure will be quite different in the two cases. In one case, he will 
attempt the typical amputation of the text-book; in the other, his 
sole guide will be the preservation of tissue: he will do an atypical 
amputation. 

(A) The soft parts are more extensively destroyed than the bone. 
This is nearly always the case in traumatism and always the case 
in gangrene. The site of amputation will depend upon the limit of 
the sound skin; the rule is to remove none of the healthy soft parts; 
the line of incision should follow the line of demarcation, and having 
fashioned the flap following this indication, divide the bone high 



73° SOME PRACTICAL AMPUTATIONS 

enough to accommodate the flaps, and no higher. (See also Injuries 
to the Extremities.) 

(B) In case the bone is more extensively destroyed than the 
soft parts, as in tuberculosis, sarcoma, etc., one has more option; he 
can fashion the flaps in any manner desired, for usually much that is 
healthy will have to be removed. The position of the cicatrix can be 
determined and such is the typical amputation. 

FINGER AMPUTATIONS 

Practical anatomical points (Jacobson, Operative Surgery) : 
"The three creases in front almost correspond to the joints. The 
lower crease is just above the joint; the middle is opposite the joint; 
the highest, nearly % of an inch distal to the metacarpophalangeal 
joint. 

" The prominence of the knuckles is formed by the higher of the two 
bones; by the head of the metacarpal bone, the he^d of the first pha- 
lanx, the head of the second phalanx for the three joints respectively. 





Fig. 559. — Typical amputation of finger; palmar flap, dorsal scar. (Farabeuf.) 

"The joint in each case is below, or distal to, the prominence; the 
metacarpo-phalangeal joint is about ^ inch below the knuckle; 
the second joint, % inch below the knuckle; the terminal joint l{ 2 
inch beyond the knuckle. 

" In the distal and interphalangeal, the joint is concave from side to 
side and presents a concavity toward the finger tips. In the meta- 
carpo-phalangeal joint, the convexity is toward the finger tip. 

"From the readiness with which the tendons conduct infection, 
care should be taken to keep even so small an amputation as that of a 
finger strictly sterile, and in amputating through damaged parts the 
flaps should not be too closely united with sutures.'' 

It is a rule with but few exceptions to save as much of the finger as 
possible, and it will almost always happen in removing part of a finger 



AMPUTATION OF FINGER 



731 



that an atypical amputation will be indicated. Let the scar fall 
where it will, making a dorsal or a lateral flap if necessary. ■ The 
palmar flap and dorsal scar is ideal, but rarely attainable (Fig. 562). 
There are, however, surgeons of large experience who insist that a 
palmar flap be secured even at the cost of more finger, and that less 
than half a phalanx should not be saved, but cut back to the joint 
to avoid flexure. (See Injuries to the Hand.) 

If a distal phalanx is to be removed, begin by pronating the hand, 
forcibly flex the phalanx and divide the skin 3^2 i nc h distal to 




Fig. 560. — Atypical amputation of a finger, the bone projecting beyond the skin. 

incision. (Veau.) 



Dorsal 



the knuckle; this incision deepened will open the joint. Divide the 
lateral ligaments. The edge of the knife is carried under the phalanx 
and swept downward, grazing the bone and cutting with a steady 
sawing movement. The result is indicated in Fig. 559. Do not cut 
the flap too short, a common mistake with the inexperienced. 

AN ATYPICAL AMPUTATION 

Suppose a finger to have been sawed off. The bone projects be- 
yond the retracted skin. It is not possible to fashion a flap without 
removing some bone. 



732 



SOME PRACTICAL AMPUTATIONS 



Local anesthesia (Figs. 10 and 1 1) . Circular constriction at the base 
will control bleeding and prevent rapid absorption of the solution. 
Begin by making a dorsal linear incision an inch long down to the 
bone (Fig. 560). 

Liberate the whole circumference of the bone }/% inch up, 
either with a rugine or a bistoury (Fig. 561), and at that level divide 
the bone with bone forceps (Fig. 562). Employ two or three sutures 
with drainage if there is much chance of infection (Fig. 563). 

If the dorsal linear incision opens into a joint, the section may be 
made there — disarticulate. 





Fig. 561. — Liberating the bone. (Veau.) Fig. 562. — Section of the bone. (Veau.) 

Divide first the dorsal ligament, then the lateral ligament to the 
left, and as the phalanx is twisted toward the left, divide the lateral 
ligament to the right. Suture as before. It may be necessary to 
slice off the head of the remaining portion of the digit if it is too 
prominent. 



TYPICAL AMPUTATION OF THE WHOLE FINGER 

General anesthesia is usually necessary. The method of procedure 
is different for the middle and ring fingers, the index and little fingers, 
and the thumb. 



AMPUTATION OF FINGER 



733 



(I) The Middle and Ring Fingers. — Locate the articular line by 
making traction on the finger with one hand and palpating each side 
of the joint with the index finger and thumb of the other hand. 




Fig. 563. — Atypical amputation: Suture and drainage. (Veau.) 




Fig. 564. — Typical amputation of middle finger: Primary incision directed to 

the right. (Veau.) 

Begin the incision at the upper level of the joint; carry it obliquely 
downward and forward between the fingers so that it reaches the 
palmar surface at the right, a little below the crease (Fig. 564). 



734 



SOME PRACTICAL AMPUTATIONS 



Lift up the hand so that you face the palm and cut transversely to 
the left (Fig. 565). Now lower the hand and complete the incision, 
bringing it obliquely upward and backward to the knuckle, the start- 
ing-point (Fig. 566). 

Having outlined the incision in this manner, repeat the movement, 
cutting to the bone. Retract the flap, exposing the articulation. 



■ 



\ 




Fig. 565. — Amputation of the middle finger: Lifting the hand while making the transverse, 

palmar incision. (Veau.) 



Disarticulate. Pull on the finger to separate the joint surfaces, 
which helps to locate the joint line. Hold the bistoury vertically, 
and with its point divide the lateral ligament to the left, then the 
dorsal ligament (Fig. 567), then the ligaments to the right, at the 
same time bending the finger to the right. 

Tie the digital arteries, usually one on each side, and suture 
(Fig. 568). 



AMPUTATION OF FINGER 



735 



(II) Index and Little Fingers.— In these two instances, the aim 
is to carry the scar toward the dorsum and the axis of the hand. In 




Fig. 566. — Amputation of the middle finger. Completing the skin incision. (Veau.) 



V 




Fig. 567.— Amputation of the middle finger: Traction on the finger while the bistoury cuts 
first the left and then the dorsal ligaments. (Veau.) 

the case of the index, it falls toward the ulnar side; in the case of the 
little finger, toward the radial side. The scar is, then, in each case, 
furthest removed from pressure. 



736 



SOME PRACTICAL AMPUTATIONS 



The flap itself, of rounded outline, folds over on an axis passing 
obliquely through the joint cavity and approximates the adjoining 
finger. 

The removal of the index finger is conducted along the same lines. 

The first semicircular incision is carried around the radial side and 
completed by a second, following the web of the finger. The appear- 
ance of the flap is indicated in Fig. 573, and the final result in Fig. 574. 




Fig. 568. — Amputation of the middle finger completed. (Veau.) 

If the patient is a laborer, it is necessary to render the hand as use- 
ful as possible, nor must the cosmetic effect be neglected. It is neces- 
sary to reduce the size of the heads of the metacarpal bones. 

The head of the metacarpal bone of the index is best reduced by an 
oblique section of the radial side; of the little finger, the ulnar side; 
of the ring finger, by transverse section (Fig. 575). With regard to 



AMPUTATION OF LITTLE FINGER 



737 





Fig. 569. — Amputation of the little 
finger: Flaps completed. (Veau.) 



Fig. 570. — Amputation of the little finger: Disar- 
ticulation, cutting from left to right. (Veau.) 



In the case of the little finger, begin the incision just below the joint line on the ulnar 
side of the extensor tendon, and carry it obliquely downward and forward and then across 
the palmar surface, inscribing a regular semicircle which ends at the free border of the web 
between the little and ring fingers. Complete the incision by cutting from this point to the 
starting-point, inscribing a semicircle with its concavity toward the web. Follow this same 
track again, cutting to the bone. Denude the bone completely (Fig. 569). 

Disjoint, dividing the left and the dorsal and finally, the right lateral ligament (Fig. 
(570), and the flap is free (Fig. 57i). Suture (Fig. 572). 





Fig. 



S7i. — Amputation of the 
Flap after disarticulatin. 

47 



little finger : 
(Veau.) 



Fig. 572. — Amputation of the little finger: 
flap sutured. The line of union lies toward 
the axis of the hand on the dorsum. (Veau.) 



738 



SOME PRACTICAL AMPUTATIONS 



the middle finger, the head of its metacarpus should not be removed 
unless shapeliness rather than strength is desired (see page 105). 

(Ill) The Thumb.— The thumb must be treated with the utmost 
conservatism. The smallest part must never be removed unneces- 
sarily, as it is almost as useful as the rest of the fingers together, 





Fig. 573- — Amputation of index; showing Pig. 574- — Amputation of index and little 
form of flap. {Veau.) fingers completed. (Veau.) 



and nearly always after a traumatism, it is best to do an atypical 
amputation. (Figs. 582, 583, 584.) 

In the typical amputation, employ a palmar flap. Begin on the 
dorsal surface just below the articular line and incise to the right, 
reaching the edge of the palmar surface just above the interphalan- 
geal crease. (Fig. 580.) 



SECTION OF THE METACARPALS 



739 



In the course of a finger amputation, once the finger is disarticulated at the metacarpo- 
phalangeal joint (amputation of whole finger), the treatment of the corresponding meta- 
carpal head is to be considered. 

The mode of procedure varies with the various fingers and is determined by two 
factors: The future appearance of the hand; and, second, its usefulness. 

Fortunately the best cosmetic effect is consistent for the most part with conservation 
of function. Formerly we were advised to leave the metacarpal head intact whenever 
it was desired to maintain the whole strength of the hand. This was based on the 
notion that destroying the transverse ligaments left the metacarpus unstable and the 




Fig. 575. — Lines of section of the metacarpal heads. (Veau.) 



hand weakened in consequence; but the line of section need not extend so far beyond 
the articular surface. The line of section differs with the various digits as indicated in 
Fig. 575- 

Thus the metacarpal head of the index and little fingers is sectioned obliquely to 
smooth off, in the one case the radial, in the other, the ulnar border of the hand. Com- 
pare Fig. 574 with figures on page 102. 

The Ring Finger. — Divide the metacarpal head transversely (see page 103). 

The Middle Finger. — The metacarpal head is best treated by slicing off a part of each 
lateral surface. If none is removed the separation of the adjacent fingers is too wide 
Fig. 568"). If too much is removed the index finger falls away from the thumb inter- 
terring with apposition (see page 104). 



74o 



SOME PRACTICAL AMPUTATIONS 




Fig. 576. — Crush of ring finger. Treatment. 



Every crush of the fingers must be treated with the greatest conservatism. The 
temptation to get rid of the mangled tissues and to make a sightly stump is always 
great but the patient's mind dwells more strongly on the loss of tissue. In many cases 
it is impossible to say what effort the tissues may make toward repair. Trim the skin 
sparingly therefore. Carefully disinfect and splint in such manner as not to interfere 
with the circulation and wait for further indications. 

However, a finger crushed in the manner indicated in Fig. 576, it is useless to save, 
because it will be deformed, unsightly and an actual hindrance. Usually the tissues 
slough and there is constant danger of infection involving the whole hand. It is best to 
disarticulate at once at the metacarpo-phalangeal joint. 

Begin with a dorsal incision extending 1/2 inch above the head of the metacarpal 
bone, freely exposing the extensor tendon. The incision is now carried around the base 
of the finger (Fig. 577). 



AMPUTATION OF FINGER 



741 




Fig, 577. — Crush of ring finger. Amputation. 

Second step: Raise the finger so that the palmar surface presents and beginning at the 
dorsal incision cut from left to right along the base of the finger keeping within the limits 
of sound tissue. Cut down to the bone, dividing the flexor tendons and on either side 
the digital arteries. Having divided all the soft parts denude the bone with a rugine or 
periosteal elevator, exposing the head of the metacarpus thoroughly (Fig. 578). 

Third step: Disarticulate by dividing the ligaments, first the dorsal, then the right 
lateral, and the left. The joint is now widely opened so that the palmar ligaments are 
exposed and easily divided (Fig. 578). 

Fourth step: Resection of the Metacarpal head. Grasp the exposed bone with a bone- 
holding forceps and divide it transversely with a saw or bone shears (Fig. 579). Com- 
plete the hemostasis, ligating the digital arteries. Suture. 



742 



SOME PRACTICAL AMPUTATIONS 




Fig. 578. — Crush of ring finger. Third step in amputation. (Lejars.) 







Pig. 579. — Crush of ring finger. Fourth step in amputation. (Lejars.) 



AMPUTATION OF FINGER 



743 





Fig. 580. — Line of incision in typical am- Fig. 581. — Lines of incision in removing 
putation of the thumb. (Farabeuf.)a. a finger with its metacarpus. (Veau.) 

The line of incision in typical amputation of the thumb should mark off, if possible, a 
palmar flap (Fig. 580). Begin the incision on the dorsal surface below joint line. Cut to 
the right, reaching the palmar surface at the interphalangeal crease. Continue the in- 
cision across the palmar surface. Now go back to the starting point and make an incision 
similar to first on the opposite side, completing outline of flap. While the assistant now 
steadies thumb, dissect the flap including all the soft parts down to the bone, dividing 
the flexor tendon and finally exposing the joint. Let the assistant now retract the flap 
while you pull on the thumb bringing the joint line into relief. Section the ligaments to 
the left, above and to the right successively. Drain and suture. 

Trace of incision for removing the finger with its metacarpal. Note that incision begins 
on the back on the line connecting the bases of the metacarpal bones of thumb and little 
finger; extends along dorsum of metacarpus and branches above level of its head Fig. 581). 
The head of the metacarpus is cleared and the denudation, sometimes difficult, carried 
toward the wrist. The point of the knife is inserted in the joint lines to disarticulate. 
Care must be taken to avoid the deep palmer arch which lies adjacent. 



744 



SOME PRACTICAL AMPUTATIONS 






/MM 




FlG. 582. — Crush of the Thumb. 
Atypical amputation. 




Fig. 583. — Crash of Thumb. Atypical 
amputation. First step. 



A crushed thumb must be treated with the greatest conservatism since even the shortest 
stump is useful, the metacarpal bone has all the value of a phalanx in the other digits 
(Fig. 582). 

Do an atypical amputation. Let the primary incision follow the line of viable tissue, 
cutting down to the bone. Denude the bone with the rugine (Fig. 583). Resect so 
that the skin flaps will fall into place without undue stretching. 

It must be remembered that the vitality of the flaps is lowered and if they are stretched 
tightly over the end of the bone are sure to slough. The drainage must be ample (Fig. 
584). 



AMPUTATION OF FOREARM 



745 



.TYPICAL AMPUTATION OF THE HAND (Traumatism 
of the Metacarpals) (Fig. 585) 

It is often inadvisable to amputate at once, for parts that seem 

[evitalized may survive. Check the hemorrhage and disinfect and 

await the course of events. The limits of viable tissue can soon 

be determined. The technique is sufficiently indicated in Figs. 

S85 ? 586, 587, 588, 589- 



AMPUTATION OF THE FOREARM 

Disarticulation at the wrist is very rarely done in general practice. 
If a tuberculosis of the wrist calls for intervention, amputate the 
forearm (Fig. 590). 




Fig. 584. — Atypical amputation of the thumb complete; part of metacarpus preserved. 

Drainage. (Lejars.) 

Following traumatism, do an atypical amputation, conserving as 
much as possible of the member. 



746 



SOME PRACTICAL AMPUTATIONS 




Fig. 585. — Crushing injury to hand. Useless to try to save any but the index 

finger. (Veau.) 




Fig. 586.— The metacarpals are denuded upward for an inch; all the soft parts 

saved. (Veau.) 



AMPUTATION OF HAND 



747 




Fig. 587. — Section of metacarpals with bone-cutting forceps. (Veau.) 



In the case of a crush of the hand involving the metacarpus, no effort is made to do 
a typical amputation; the whole effort is to save as much useful tissue as possible. 
!As indicated in Fig. 586 denude the bones as high up as the skin flaps, after having 
been properly trimmed, require. Sometimes it will be advisable to wait for a day or 
two to see how much of the soft parts will live. Accordingly the hand is carefully dis- 
infected. A moist antiseptic dressing is applied and kept under close observation until a 
line of demarcation occurs. 

, Once the level of bone section is determined resect with bone forceps, suture loosely 
with ample drainage, but be sure of the hemostasis. 

If infection develops, remove the sutures and use prolonged immersion in hot normal 
salt solution. 



748 



SOME PRACTICAL AMPUTATIONS 



Typical amputations of the forearm are most easily performed at 
any level, by a modified circular incision; for Technic, see Figs. 591. 
59 2 > 593> 594, 595> 596, 597, 598. 




Fig. 588. — Amputation completed. (Veau.) 



AMPUTATION AT THE ELBOW- JOINT 

Make a circular incision 3 inches below the joint, involving the 
skin and fascia. Turn back the cuff to the joint. Divide the mus- 
cles over the joint line. Divide the lateral ligaments. Open the 
outer side of the joint first and, directing the assistant to make trac- 
tion on the arm, separate the ulna and divide the triceps. Tie the 
arteries, resect the nerves, and suture. 



AMPUTATION AT SHOULDER JOINT 



AMPUTATION OF THE ARM 



749 




Fig. 589. — Am- 
putation of the 
hand. Thumb 
saved. (Senn.) 



Apply an Esmarch tube high up near the axilla, 
or an assistant may compress the artery in the 
upper part of the arm or behind the clavicle. 

Stand to the outer side of the arm. Retract the 
skin with the left hand if operating on the right 
arm, or direct the assistant to retract the skin if 
operating on the left arm. The skin section must 
lie about one diameter below the proposed bone 
section (Fig. 599). The successive steps of the 
operation are indicated in Figs. 599, 600, 601, 602, 
603. 

AMPUTATION AT THE 
SHOULDER-JOINT 

Amputation at the shoulder may be per- 
formed by a variety of methods, each of which 
has its advantages and disadvantages. The 
special points to be thought of in making the 
operation are the control of hemorrhage, good 
drainage, easy disarticulation and a good stump. 
No one operation, perhaps, secures all of these 
principles in equal degree. 

Spence's method is recommended as generally 
serviceable. 

Recall the principal landmarks of the 
shoulder-joint, the acromion process, the cora- 
coid, the tuberosities; recall the attachments 
of the various muscles; and the relations of the 
blood vessels. 

The patient is placed with his shoulder close 
to the edge of the table, with shoulder elevated, 
and face turned to the opposite side. The 
operator stands to the outer side. 

The operator aims at the exposure of the joint 
and disarticulation, and finally the formation of 
an axillary flap. 




Fig. 590. — Amputa- 
tion of the forearm. 
Tuberculosis of the 
wrist. (Veau.) 



75° 



SOME PRACTICAL AMPUTATIONS 




Fig. S9i. — Amputation of the forearm Beginning the circular incision, which must fall 
well below proposed line of bone section. 




Fig. 592. — Amputation of the forearm. Completing the circular incision. Not only the 
skin but the fascia as well must be completely divided. 



AMPUTATION OF FOREARM 



751 




Fig. 593. — Lateral incisions extending upward two or three fingers' breadth, favor 

retraction of skin curl. 




I Fig. 504 — Third step. Transfix muscles at upper level of lateral vents, point of knife 
grazes bones. Hand must be supinated and flexed to relax muscles of forearm. 



752 



SOME PRACTICAL AMPUTATIONS 




Fig. 595.-— Complete the anterior flap by cutting outward following the transfixion. Re- 
peat the process, passing the transfixing blade posterior to bones and fashion posterioi flap 
in same manner. (Veau.) 




Fig. 596. — The flaps formed, it remains to divide the interosseous membrane and at 
tached muscles, and the periosteum. The direction which the point of knife takes is indicatec 
by the arrows. 



AMPUTATION OF FOREARM 



753 




Fig. 597- 




Fig. 598. 

Fig. 600 shows manner in which the periosteum is stripped back after all the soft parts 

are divided. The bones are completely denuded to level of section previously determined. 

I Use a three-tailed retractor to pull the skin flaps out of the way of the saw partly divide 

t the ulna, saw through the radius and complete section of the ulna. Ligate all vessels, trim 

the median and ulnar nerves. Fig. 601 shows the manner of applying drainage which should 

nearly always be used, and of suturing the skin flaps. 

48 



754 SOME PRACTICAL AMPUTATIONS 

Incision. — (i) Begin just in front of the coracoid process and cut 
vertically downward to the lower level of the tendon of the pectoralis 
major, keeping in front of the groove between the pectoralis major 
and deltoid. This incision should reach the bone; the pectoralis 
major tendon is divided. The bleeding comes from the humeral 
branches of the acromio-thoracic and from the anterior circumflex. 
These vessels may be clamped. 

(2) Next carry the incision outward across the arm, making a 
slight curve, convex downward, and ending at the axillary border 
behind. All the structures are divided to the bone. The deltoid is 
divided just above its insertion and the hemorrhage comes from the 
muscular branches. 

The next step consists in outlining the internal flap by making an 
oval skin incision, which extends from the termination of the first 
across the inner surface of the abducted arm to the end of the vertical 
part of the first incision (Fig. 604). 

The third step consists in elevating the external flap which con- 
tains the deltoid. It is easily dissected and by this means the joint 
is exposed. The posterior circumflex artery must not be injured 
and is preserved in the deltoid flap. 

The fourth stage: Disarticulate. Begin by dividing the biceps 
tendon and the capsule with a transverse cut. Rotate the arm in- 
ward and divide successively the tendons of the teres minor, the in- 
fraspinatus, the supraspinatus; rotate the arm outward and divide 
the tendon of the subscapularis. If the humerus has been broken, 
rotate the head by means of a bone forceps. 

Dislocate the head, divide the capsule behind and push the head 
up to the level of the acromion; drawing the head outward, slip the 
knife behind the head and prepare to complete the section of the 
soft parts. If the axillary has not been previously ligated, the assist- 
ant grasps the upper part of the flap about to be divided and his 
hands follow the knife downward ready to compress the artery as 
soon as divided. 

The knife follows the bone till opposite the skin incision when it 
cuts directly through the soft parts that the vessels may not be di- 
vided obliquely. The arm is now completely removed. 

The next stqp consists in ligating the vessels and in trimming the 



AMPUTATION OF ARM 



755 




Fig. 599. — Amputation of the Arm. Circular flap. (Veau.) 
Supposing an amputation af the right arm, grasp the arm above the proposed incision, 
j with left hand, pulling the skin tight while the assistant supports the member. First 
* step: Make a semicircular cut from the inside, over the front and to the outside. Repeat, 

1 passing from the inside behind the arm. Avoid wounding the artery on the inside. 
Divide the skin and fascia only. There will be considerable venous hemorrhage which is 
to be disregarded. There will be about an inch gap when the skin and fascia are com- 
pletely divided. The next step is liberation and further retraction of the skin flap. 



75^ 



SOME PRACTICAL AMPUTATIONS 




Fig. 600 — Amputation of the arm. Circular flap. (Veau.) 



Second step: Free the skin flap. Divide the fascial attachments with the point of the 
knife but do not button-hole the skin flap. The fascial attachments are firmest over the 
line of the artery and a little patience is necessary in freeing them. Loosen the skin until 
there is a gap of at least iJ4 inches. The flap must be well mobilized. You are ready 
now to make a circular section of the muscles. 



AMPUTATION OF ARM 



757 




Fig. 6oi. — Amputation of the arm. Circular flap. 



Third step: First circular section of the muscles. The soft parts, skin and muscles are 
to be strongly retracted, either by the operator's left hand or by an assistant. By a circu- 
lar sweep of the knife divide the muscles at the level of the retracted skin. Divide all 
the structures down to the bone. But they do not contract evenly; therefore a second 
circular section is required. 



758 



SOME PRACTICAL AMPUTATIONS 




Fig. 602. — Amputation of the arm. Second circular section of the muscles. 




Fig. 603. — Amputation of the arm. Denudation of the periosteum. 
Fourth step: Second circular section of soft parts at level of retracted skin, forming a 
stump with a smooth even surface (Fig. 602). The blood vessels are easily identified 
and should be ligated at this time. Fig. 603 shows the next step which consists in the 
denudation of the bone, stripping back the periosteum to the level of the proposed bone 
section when the bone is sawed. Remove the tourniquet and complete the hemostasis. 
Suture the periosteal flaps over the bone if possible. Mattress suture the muscles and 
fascia. Drain. Suture the skin. 



AMPUTATION AT SHOULDER 



759 



axillary nerves and in suturing the flaps so as to form a vertical scar 
as nearly as possible. The glenoid fossa may be curetted. 

For the control of hemorrhage, Wyeth's plan of constriction may 
be followed. An elastic ligature held in place by two pins passed 
through the soft parts before and behind the shoulder compresses 
the axillary vessels. 



AMPUTATION ABOVE THE SHOULDER 

This operation, bloody and often fatal, may need to be undertaken 
for malignant disease in the vicinity of the shoulder-joint or as an 
emergency in the case of crushing injury to 
the shoulder or of gunshot wounds. 

The procedure as defined by Berger con- 
templates the resection of the middle third 
of the clavicle and ligation of the subclavian; 
the formation of the antero-inferior and a 
postero-superior flap; and finally the division 
of the muscles connecting the scapula with 
the trunk. 

The operation is thus described: 

Place the patient on his back close to the 
edge of the table, with the shoulder slightly 
elevated. Begin the incision over the cla- 
vicle at the outer border of the sterno-mas- 
toid, and follow the clavicle outward to the 
acrominal end, cutting to the bone. Denude 
the middle third of its periosteum with the 

rugine, and divide the bone at the junction of the inner and middle 
thirds. Elevate the bone and divide again at the junction of the 
middle and outer third. Separate by blunt dissection the fascias 
overlying the subclavian vessels and first ligate the artery at the 
outer border of the first rib and then the vein. 

Now change the patient's position: the shoulder is brought over the 
edge of the table, the arm abducted, and the head turned to the 
opposite side. 

Form the antero-inferior flap. Begin an incision at the middle of 




Fig. 604. — Spence's am- 
putation. (Moullin.) 



760 SOME PRACTICAL AMPUTATIONS 

the first and carry it obliquely downward and outward; just to the 
outer side of the coracoid process, along the anterior border of the 
deltoid, to the axillary border and thence across the inner surface of 
the arm just below the axillary fold and thence down the axillary 
border of the scapula. Divide the pectorals and the latissimus dorsi 
close to their insertions. Resect the nerves of brachial plexus. 

From the postero-superior flap.' Begin the incision over and just 
internal to the acromio-clavicular joint and carry it downward over 
the spine of the scapula to the lower angle of the scapula, where it 
joins the preceding incision. Dissect the flap and expose the muscles. 
Divide first the trapezius and then with heavy scissors divide close 
to the bone, the muscles attached to the posterior border, the serratus 
magnus, the rhomboideus major and minor, and the levator anguli 
scapulae. 

The arm falls away. Complete the hemostasis and drain through 
button-holes in the flaps in the axilla and scapular region. Bandage 
firmly so as to obliterate the cavities. 

AMPUTATION OF THE TOES 

These amputations are more frequently consequent upon trauma- 
tism; occasionally for deformity or other painful conditions. 

In the amputation of fingers, as much as possible is saved; in the 
amputation of toes, the whole toe is nearly always removed. In 
consequence these amputations are usually typical, for one does not 
so much need to concern himself with the conservation of tissue. 

In the case of total ablation of the finger, a part of the metacarpal 
head must usually be removed to enhance function; the head of the 
metatarsals must always be saved, where possible, to preserve the 
functions of the foot. 

The position of the cicatrix demands more attention in the case of 
the toes. A special effort must be made to leave the scar farthest 
from pressure; that is, dorsal and to the inner side with reference to 
the axis of the foot. 

Local anesthesia is often sufficient, forming an anesthetic ring 
around the entire toe, involving the skin. The injection may need 
to be renewed for the deeper tissues; and before disarticulation, 
inject the joint. 



AMPUTATION OF TOE 



761 



AMPUTATION OF THE GREAT TOE 

In amputation of the great toe, the flap resembles that of the index 
finger and the scar adjoins the base of the second toe. 

Begin by locating the joint line. The incision commences just 
below this, and over the tibial border of the extensor tendon, and 
extends with a slight outward convexity, downward and forward to 
the interphalangeal crease on the plantar surface and across the pal- 
mar surface obliquely, ending at the web. 

Begin on the dorsum again at the original starting-point and with a 
slightly curved incision, join the ends of the first (Fig. 605). 





// 


f. m 1 / 
I ' w 

1 ' ; 




lo) 


\ 

w 





Fig. 605. — Lines of incision for am- 
putation of big toe. (Farabeuf.) 



Fig. 606. — Amputation of big 
toe completed. (Farabeuf.) 



Fig. 607. 



Dissect the flap, keeping close to the bone, so that all the soft parts 
shall be preserved in the flap. Divide the flexor tendon — sometimes 
rather difficult. 

Disarticulate. Divide, first, the lateral ligaments to your left, then 
the dorsal, and finally those at your right. Divide the plantar liga- 
ments, twisting the toe, as in the case of the finger. Employ drain- 
( age; pull the flap into position and suture. The shape of the flap and 
the position it assumes are represented in Figs. 606 and 607. 



762 



SOME PRACTICAL AMPUTATIONS 



AMPUTATION OF THE LITTLE TOE 

Incision. — Begin at the inner end of the joint line and cut obliquely 
downward and outward, meeting the plantar surface at the joint line 
below, and then backward and inward toward the web (Fig. 608). 
In this manner a convex flap is formed (Fig. 609). Dissect the flap, 
preserving in it all the soft parts. Expose the joint line. 

Disarticulate. Making vigorous traction on the toe, divide in 
regular order the lateral, the dorsal, the lateral (to your right), and 
plantar ligaments. 




Fig. 608. Fig. 609. Fig. 610. 

Figs. 608 to 610. — Amputation of the little toe. (Farabeuf.) 

Drain from the upper part of the incision and suture. The posi- 
tion of the cicatrix is represented in Fig. 610. 

AMPUTATION OF ONE OF THE MEDIAN TOES 



Incision. — The line of the joint having been determined, begin just 
above it on the dorsum, incising forward and downward to just be- 
low the web, crossing the palmar surface and back to the starting- 
point, completing the racket (Fig. 611). Remember that the meta- 
tarsophalangeal joint is considerably above the line of the web. 
Denude and divide the flexor tendon. 

Disarticulate in the manner already described for the other toes. 
Drain from the upper end of the incision and suture (Fig. 612). 



AMPUTATION OF TOE 



763 





Fig. 611. — Line of incision for amputation Fig. 612. — Suture and drainage after 
of toe. (Veau.) amputation. (Veau.) 




Fig, 613. — Lines of incision for removal of toes with head of corresponding 

metatarsals. (Veau.) 



764 SOME PRACTICAL AMPUTATIONS 

AMPUTATION OF A TOE WITH PART OF ITS 
METATARSUS 

This amputation presents some difficulties in dissecting the flaps, 
because of the palmar projection of the head of the metatarsal. 

The incision is racket-shaped, as in amputation of the toe, but it 
begins higher up, above the level of the diseased bone, and runs down 
to the web, across the palmar surface and back to the starting-point, 
as represented in Fig. 613. To dissect the flaps for the middle toes, 
denude the dorsum of the metatarsus and divide it with the bone for- 




Fig. 614. — Amputation of big toe with head of metatarsal. (Farabeuf.) 

ceps, and lifting upon the divided end, dissect forward along the pal- 
mar surface. 

The metatarsus of the little and great toes may be sawed. In 
forming the flap for the great toe and its metatarsus (Fig. 614) do not 
forget to remove the sesamoid. Drain as in amputation of the toes 
and suture. 



AMPUTATION OF A PART OF THE FOOT 

As in the case of the hand, the rule is to conserve as much as pos- 
sible of the foot with this proviso, that a painful mass of scar tissue 
does not form in the stump and the action of the flexors of the foot is 
retained. 

In the case of traumatism or gangrene, where the soft parts are 
more involved than the bone, the line of section follows the healthy 
skin and the bone section will be made to accommodate itself to the 
skin flaps. 

Atypical Amputation. — If the case is one of tuberculosis, the bone is 



AMPUTATION OF FOOT 



76S 



more involved than the skin, and one may determine the upper limit 
Df the diseased bone and divide it there. In such a case, one may 
iashion a palmar flap, and make a dorsal scar — the typical amputa- 
tion. But, as Veau says, do not concern yourself with the formal 
operations, such as a Lisfranc or a Chopart — excellent exercises on 





Fig. 615. — Following the line of demarca- 
tion. Atypical amputation. (Veau.) 



Fig. 616. — Dividing the bones. (Veau.) 



the cadaver — but saw the bones where you must, to remove all the 
disease. 

In the case of gangrene or traumatism, then, divide the tissues to 
the bone, along the line of demarcation. 

The borders of the palmar and dorsal flaps must correspond to 
the borders of the foot (Fig. 615). Once the soft parts are divided, 



766 



SOME PRACTICAL AMPUTATIONS 



they should be retracted by dividing their attachments close to the 
bone, and the bones are divided high enough for the flaps to come 
together (Fig. 616). 

In the case of tuberculosis make a transverse incision dorsally and 





Fig. 617. — Suturing extensor tendons 
to skin flap. (Veau.) 



Fig. 618. — Suture and drainage. (Veau.) 



shape the long palmar flap by transfixion and cutting outward, or by 
cutting from without inward (Fig. 617). 

Suture the tendons to the periosteum or fibrous tissues, for if the 
tendo-achilles is left unopposed the result will be a useless stump. 
Resect the nerves and suture, using drainage (Fig. 618). 



AMPUTATION OF FOOT 767 

TOTAL AMPUTATION OF THE FOOT 

In total amputation of the foot, the exact procedure will depend 
chiefly upon the condition of the os calcis. If it is sound, Pirogoff's 
osteoplastic amputation is indicated. If the os calcis is diseased, 
Symes' amputation is indicated — a disarticulation at the ankle-joint, 
with erasion of the malleoli. But one cannot always determine be- 
forehand the state of the os calcis, and therefore an incision should be 
made which will permit either procedure after the os calcis has 
been examined. 

First Incision. — -The first incision extends across the sole with one 
end at. the tip of the external malleolus and the other a finger's 




Fig. 619. — Line of incision for complete amputation of foot. (Vean.) 

breadth below the tip of the internal malleolus. (The internal mal- 
leolus does not extend quite so low as the external) (Fig. 619). 

An assistant elevates the limb; you seize the foot with the left hand 
I and make this plantar incision from left to right; that is to say, in the 
case of the right foot begin the incision at the end of the outer malleo- 
lus and terminate it a finger's breadth below the internal. In the 
case of the left foot, begin at the internal and end at the external 
malleolus. 

Repeat the movement several times, for there is always consider- 
able difficulty in accomplishing complete section of the tendons, some 
of which are oblique to the line of incision and others deep and im- 
bedded in grooves. 

Second Incision. — -Connect the extremities of the first incision by a 



768 



SOME PRACTICAL AMPUTATIONS 



dorsal incision, which should be slightly convex forward toward the 
toes. This line crosses over the head of the astragalus. The foot 
should be lowered and the cut made from left to right. Extension 
of the foot will facilitate the division of the anterior tendons and 
ligaments. 

Now distinguish the head of the astralagus, and between it and the 
articular surface of the malleolus pass the point of the knife and cut 





Fig. 620. — Section of the lateral ligaments. 
(Veau.) 



Fig. 621. — Clearing the upper and internal 
surfaces of the os calcis. (Veau.) 



downward (Fig. 620). By this means, the lateral ligaments are 
divided. 

The posterior ligaments are divided by cutting along the upper 
surface of the os calcis (Fig. 621). The joint is now freely exposed 
and the os calcis may be brought into view and examined. In exam- 
ining the outer side, dissect back the soft parts for an inch, but not 
quite so far on the inner side. To be sure of the condition of the bone, 
its substance must be inspected. 



AMPUTATION OF FOOT 769 

(A) Suppose the Os Calcis is Sound, — Grasp the foot firmly with 
the left-hand, depress it and pull upon it at the same time, while the 
assistant retracts the flaps, which have been loosed from the sides of 
the bone. 

The flaps are held back by retractors on each side, which are 
slipped down with the progress of the saw r , the assistant bracing his 
thumbs against the heel. 

The saw is started in the upper face of the os calcis, a finger's 
breadth behind the astragalus in a manner to take off a slice from 
above downward and forward (Fig. 622). With the completion of 




Fig. 622. — Section of the os calcis. The saw directed downward and forward. The re- 
tractors slipped downward as the saw progresses. (Farabeuf.) 



this section, the foot is removed, and. the posterior part of the divided 
os calcis is left in the heel flap. 

The next step is to saw off the malleoli. Begin by completely de- 
nuding these processes of their covering, skin, fascia and tendons. 
C^rry the denudation upward, a distance of two fingers' breadth be- 
hind; just above the level of the articular surface of the tibia, in front. 
The posterior tendons especially are sometimes difficult to dislodge 
from their groove. 

The line of section being thus cleared, the heel flap is held well up 
toward the calf, out of the way, by the assistant, who also supports 
the leg in the horizontal position. 

It is well for the operator to steady the limb by seizing one of the 

. malleoli with a bone-holding forceps. The saw enters just above the 

] articular line in front, and emerges a full finger's breadth above that 

level (Fig. 623). If the section is not carefully made, the coapta- 

49 



770 



SOME PRACTICAL AMPUTATIONS 



tion of the sawed surface of the os calcis to that of the tibia may 
be imperfect. 

Complete the hemostasis, bring the two bone surfaces together, and 
suture the anterior tendons to the fibrous covering of the under sur- 
face of the os calcis, the better to fix this stump in position. If it is 
feared the bone will slip, one or two bone sutures may be employed. 
Suture the skin, usually employing drainage. 

(B) Suppose the Os Calcis is Diseased. — In case the os calcis is dis- 
eased, it must be entirely removed, instead of sawed. 




Fig. 623. — Parts removed in Pirogoff's amputation represented in dark. (Veau.) 

The left hand strongly flexes the foot, until the posterior end of the 
os calcis points upward (Fig. 624), and as the point of the knife dis- 
sects the tissues off the left side, the foot is rotated to the right, and 
when working on the right side, rotated to the left; in this manner the 
os calcis is finally enucleated, being careful to follow the bone closely 
and not to " button-hole " the flap. 

Remember the principal vessels are to the inner side and are to be 
lifted up with the flap. 

Especial care is required when the attachment of the tendo-achilles 
is divided; the bone must be shaved, for it is here practically sub- 



AMPUTATION OF FOOT 



771 




Fig. 624. — Denudation of the posterior surface of the os calcis. (Farabeuf.) 




Fig. 625. — Syme's amputation of the foot. (Farabeuf.) 



772 



SOME PRACTICAL AMPUTATIONS 



cutaneous, and it is easy to puncture the flap. You may expect 
this stage to be tedious. 

Finally the foot will be removed (Fig. 625). 

Now denude the lower end of the bones of the leg, observing that 
the tendons in front are held down by their fibrous sheaths. In 
order to facilitate this dissection, sweep the point of the knife around 
the bone, keeping it in close contact with the bone. This dissection 




Fig. 626. — Suture and drainage. (Veau.) 

must be carried upward for an inch and the malleoli will be com- 
pletely exposed. 

Steady the leg with a bone-holding forceps, and saw the bones at 
the level of the cartilage. Begin by notching the tibia, then com- 
plete the section of the external malleolus and terminate with the 
section of the tibia. If some cartilage remains, it may be scraped off. 

Resect the nerves, suture and drain (Fig. 626). 

AMPUTATION OF THE LEG 

The leg may be amputated at any level. Formerly, when sup- 
puration was the rule, and the cicatrix was large, adherent, and pain- 



AMPUTATION OF LEG 



773 



ful, prohibiting the use of artificial limbs, the " point of election" 
was high up. The knee was flexed and the patient made use of a 
" peg-leg," the weight falling on the patella (Fig. 627). 

With present methods the scar is a matter of less concern and the 
aim should be to amputate as low down as possible, to the end that 






Fig, 627. — Knee flexed for 
"peg-leg." (Veau.) 



Fig. 628. — Artificial limb Fig. 629. — Amputation of 
applied. (Veau.) leg. Lines of section of soft 

parts and bone. (Veau.) 



the muscles may be preserved to render efficient an artificial limb 
(Fig. 628). 

This principle is true only within certain limits. Amputations 
just above the ankle never furnish a good stump for an artificial limb. 
It is better to amputate at the junction of the middle and lower thirds. 



774 



SOME PRACTICAL AMPUTATIONS 






In the case of traumatism and gangrene, then, do an atypical 
amputation, preserving carefully the sound tissue and dividing the 
bone to accommodate the skin flap. 

If the bone is involved to a greater extent than the skin, as in 
tuberculosis, a typical amputation may be done. If the stump be- 
low the knee is 4 inches long it can manage an artificial limb. 





Fig. 633. — Loosening the attachments of 
the flap to the tibia. ( Veau.) 



Fig. 634. — Dissecting up the muscles 
with the artery. (Veau.) 



There are numerous methods of amputating the leg, some appro- 
priate to one level and some to another, but for the sake of simplicity 
but one need be described — one which may be used with fair success 
in any part of the leg. In any case avoid redundancy of flap if an 
artificial leg is to be worn. 

Incision. — Begin with a circular incision of the skin about 2M 
inches below the level of the proposed bone section (Fig. 629). This 
incision will divide the skin and aponeurosis. If front, carefully 



AMPUTATION OF LEG 



775 



separate the skin from the tibial crest (Fig. 630). Next divide the 
muscles at the level of the retracted skin. Divide the muscles 
completely, but make the incision oblique to the axis of the limb, so 
that the incision reaches the bone at a higher level than at the sur- 
face (Fig. 631). 

To be certain that all the muscles are divided, one may re-pass the 
bistoury, as in the forearm (Fig. 596). Next denude the bones with 
the rugine, reaching above the level at which the bones are to be 
sawed. This denudation is most difficult and 
tedious behind, on account of the fibrous at- 
tachments of various muscles. 

The interosseous membrane is to be detached 
by a few vigorous strokes with the rugine from 
below upward. Divide it at the level of the 
proposed bone section. 

Retract the flaps with three gauze compresses, 
one passed between the bones, one applied in 
front and one behind; all to be held firmly by 
the assistant. 

Begin the sawing by notching the tibia, then 
completely divide the fibula and end with the 
section of the tibia. Plane off the projecting 
angle of the anterior border of the tibia, resect the nerves and ligate 
the bleeding points. Be sure the fibula is not left longer than the 
tibia to interfere with an artificial limb. Drain, suture the anterior 
muscular flap to the posterior, and suture the skin (Fig. 632). 




Fig. 635. — Amputa- 
tion complete. Trans- 
verse drainage. (Veau.) 



AMPUTATION THROUGH THE KNEE-JOINT 

This operation should be done in preference to an amputation of 
the thigh. 

"The femoral artery having been controlled, the limb supported 
over the edge of the table and slightly flexed, the surgeon standing on 
the right side of either limb, marks out two broad lateral flaps as 
follows: his left thumb and index finger being placed, the former over 
the center of the head of the tibia, the latter at the corresponding 
point behind, opposite the center of the joint, he marks out (in the 



776 



SOME PRACTICAL AMPUTATIONS 



case of the right limb) an inner flap by an incision which commences 
behind at the index finger and runs down the back of the leg for 3^ 
inches, and then curves up to the thumb. A similar flap is shaped 
on the outer side. 

"The inner flap must be slightly larger, in view of the large side of 
the inner condyles. 

" The flaps consist of skin and fascia. When they have been raised 
to the level of the articulation, the ligamentum patellae is severed, 



- 



/ 




yu*te< 



7 



Fig. 633. — Amputation of thigh. Circular incision of the skin. 



allowing the patella to go upward. The soft parts around the joint 
are then cut through with a circular sweep and the leg removed. In 
doing this, the limb being flexed to relax the parts and facilitate 
opening the joint, the semicircular cartilages will very likely be found 
encircling the condyles of the femur and are to be left in situ by 
dividing the coronary ligaments which tie them to the tibia. The 
condyles should always be saved if possible for they favor the useful- 
ness of an artificial limb. Resect the nerves, ligate the vessels, 
drain and suture." (Jacobson's Operative Surgery.) 



AMPUTATION OF THIGH 



777 



AMPUTATION OF THE THIGH 

Determine the level of the bone section. About the distance of one 
diameter of the limb below this level, describe a circular incision, 
dividing the skin and fascia, which may descend a little further be- 
hind than in front, if desired. 

The patient's legs are draw r n out well over the edge of the table, the 
sound limb flexed and the injured one held by an assistant. The 



\JL 



^U f 






j£ 




Fig. 634. — Amputation of thigh. Loosening the flap after a circular skin section. 



operator stands to the outside. Another assistant encircles the thigh 
above the level of the incision, with his hands. If the conventional 
amputating knife is used, begin (on the right thigh) by passing the 
knife under the limb and w T ith its heel resting upon the upper surface, 
bring it in a circular sweep back around the thigh, dividing succes- 
sively the integument of the internal, inferior and external surfaces. 
The position of the hand may be slightly changed and the incision 
continued up over the anterior surface; or that may be divided by a 
second movement (Fig. 633). 

In the meantime, the left hand has steadied the skin; the assistant 
now retracts it while its fibrous attachments are loosened (Fig. 634) 
until there is a separation of at least three fingers' breadth. At the 



77 8 



SOME PRACTICAL AMPUTATIONS 



level of the retracted skin, divide the muscles as the skin was divided, 
aiming to reach the bone. But the divided muscles do not equally 
retract, and a second circular incision of the muscles at the level of the 
retracted skin is necessary to insure a uniform stump (Fig. 638). 

Denude the femur beyond the level of the proposed bone section. 
Direct the assistant to retract the flap with two lateral compresses or 
retractors. 




Fig. 635. — •Amputation of thigh. Circular section of the muscles after retraction of skin. 

Saw the femur, ligate all vessels likely to bleed, suture the muscles 
over the end of the femur, drain, and suture the skin. 



AMPUTATION OF THE HIP- JOINT 

" Primary amputation of the hip comes under consideration in any 
extensive crush of the thigh or gunshot injury, but offers hardly any 
chance while the primary shock exists. 

"The better plan is to try and check the hemorrhage, clean the 
wound as much as possible, pack with gauze and wait. The patient 
having rallied from the shock, and gangrene, sloughing and necrosis 



AMPUTATION HIP- JOINT 779 

being imminent, amputation is indicated with a fair prospect of sav- 
ing life.* * * The first step is to control hemorrhage, * * * But there 
is one method safe and applicable to all cases and especially when the 
surgeon is unaccustomed to the operation, and that is to divide the 
common femoral vein and artery, each between two ligatures. There 
is then -no further bleeding, except from the region of the crucial 
anastomosis behind, the vessels forming which are easily picked up 
and divided." 

Formation of the Flaps. — "From the lower end of the longitudinal 
incision for tying the vessels, a circular incision is continued around 
the thigh, the skin flaps retracted and the soft parts divided as ampu- 

!tation of the thigh." (Walsham's Surgery.) 
Sennas Bloodless Amputation at the Rip- joint. — First incision: with 
the pelvis resting on the lower edge of the table, make a straight in- 
cision (beginning about 3 inches above the great trochanter) about 
8 inches in length, directly over the center of the great trochanter, 
and parallel to the long axis of the limb. When the knife reaches the 
great trochanter, its point should be kept in contact with the bone 
the whole length of the remaining part of the incision. 

The margins of the wound are now retracted and any spurting ves- 
sels secured. 

The trochanteric muscular attachments are now severed close to 
the bone with a stout scalpel. The cleaning of the digital fossa and 
the division of the obturator externus tendon, require special care. 
The thigh is now flexed, strongly abducted, rotated inward, when 
the capsular ligament is divided transversely at its upper and poste- 
rior aspect. The remaining portion of the capsular ligament is sev- 
ered, while the thigh is brought back to a position of slight flexion, 
after which it is rotated outward and, if possible, the ligamentum teres 
is cut. If this cannot be done, the head of the bone is forcibly dis- 
located upon the dorsum of the ilium by flexion, adduction and rota- 
tion of the thigh. 

The trochanter minor and upper part of the shaft of the femur are 
cleared by using a scalpel and periosteal elevator alternately. At 
the completion of this part of the operation, the femur is in a position 
bf extreme adduction and the upper portion projects some distance 
from the wound. 



780 



SOME PRACTICAL AMPUTATIONS 



If the surgeon has kept in close contact with the bone and has used 
the knife sparingly and the periosteal elevator freely, the hemorrhage 
has been slight. 

Elastic constriction is now applied. Bring the limb down in a 
straight line with the body. A long straight hemostatic forceps is 
inserted into the wound behind the femur and on a level with the 
trochanter minor when in a normal position. The instrument is 
then pushed inward and downward 2 inches below the ramus of the 
ischium and just behind the adductor muscles. As soon as the point 







Fig. 636. — Amputation at hip- joint. Elastic constriction completed by constricting the] 
posterior segment of the thigh. Flaps formed, including all the tissues down to the muscles. J 
(Senn.) 



can be felt under the skin in this location, 2-inch incision is madej 
through the skin, through which the instrument is made to emerge. 

After enlarging the tunnel made in the soft tissues by dilating the 
branches of the forceps, a piece of aseptic rubber tubing, 3 or 
4 feet in length, is grasped in the middle with the forceps and 
drawn along the tunnel as the forceps are withdrawn, whereupon the 
rubber tube is cut in two where it was held by the forceps. 

With one-half of the. tube, the anterior segment of the thigh is 
constricted sufficiently firmly to intercept both the arterial and ven- 
ous circulation completely. 



Before the constrictor is tied, the limb should be held in the vertical 
position long enough to render it practically bloodless. The elastic 
:onstrictor is either tied or, still better, held with a forceps at the 
Doint of crossing. 



AMPUTATION HIP-JOINT 



7 8l 




Fig. 637. — Senn's method of performing bloodless amputation at the hip-joint. Dislo- 
cation of head of femur ana upper portion of shaft through straight external incision. 
Elastic constrictors in place; the anterior one tied. 

The posterior segment of the thigh is constricted by the remaining 
half of the tube, which is drawn sufficiently tight behind; the ends of 
the tube are made to cross each other and are brought forward and 
imade to include the anterior segment, when they are again firmly 
drawn and tied, or otherwise fastened above the first constrictor, 



782 SOME PRACTICAL AMPUTATIONS 

furnishing an additional security against hemorrhage from the largei 
vessels in the anterior flap, when cut during the amputation 
(Fig. 636). 

After the principal blood vessels have been tied, the posterior con- 
strictor is removed and additional bleeding points are secured before 
the anterior constrictor is removed (Fig. 637). 

Surface compression with a compress wrung out of hot, normal 
salt solution, is a valuable aid in minimizing the hemorrhage, after 
the removal of the constrictors. 

"As this method of controlling hemorrhage does not require the 
presence of a skilled assistant, it will prove of especial value in emer- 
gency cases. The operation can be performed with the instruments 
contained in every pocket case. Should an elastic tube not be at! 
hand, the constriction can be made in a satisfactory manner by sub- 
stituting a cord made of sterile gauze, tightened with a lever of some 
kind, as is done in applying the ordinary Spanish windlass." (Senn, 
Practical Surgery.) 

The amputation is completed by cutting antero-posterior flaps as 
shown in Fig. 636. 



CHAPTER XXIII 

DILATATION OF THE SPHINCTER ANI; OPERATION FOR 
PILES; OPERATION FOR FISTULA 

DILATATION 

Temporary paralysis of the anal sphincter is the preliminary step 
I to most of the interventions on the rectum, and is of itself usually 
^ sufficient for the cure of fissures. 

The patient should be purged the day preceding the operation 




Fig. 638. — Dilatation of the rectum. (Veau.) 

and the rectum should be washed out with soap and water, prelim- 
inary to the actual operation. 

General anesthesia is almost indispensable and it needs to be pro- 

I found, for the anal reflex is one of the last to yield. Spinal anes- 

\ thesia is often useful in anal operations. 

7*3 



7 8 4 



DILATATION OF THE SPHINCTER ANI 



In the absence of a special dilator, begin by inserting the two 
thumbs back to back, and bracing the fingers against the outer sur- 
face of the hips, stretching the sphincter by rhythmic movements of 
the thumbs, gradually increasing the force. There is no danger of 
overdilatation, so continue until the thumbs are in contact with the 
ischial tuberosities (Fig. 638). Drainage is indicated in simple 
dilatation for fissure. 




Fig. 639. — Drainage after dilatation. (Veau.) 

Employ either one large or two or three small tubes well wrapped 
with iodoform gauze soaked in cocainized vaseline (vaseline thirty 
parts, cocaine one part), in order that the subsequent pain may not 
be so severe (Fig. 639). The tubes may be removed on the second 
day and the bowels moved on the third. 

OPERATION FOR HEMORRHOIDS 



Most cases of piles are curable by local and constitutional treat- 
ment; however, those that are very large, bleeding and inflamed, 
require an operation for their removal and radical cure. 

There are several methods of procedure, many of which are 



OPERATION FOR PILES 



78s 



successful, none dangerous and quite within the scope of every 
practitioner. 

The following may be recommended in those cases in which the 
marginal tumors are well denned but not pedunculated: 

Begin by a careful cleansing of the bowel by purgation and lavage. 
Three days before the operation, give a free purge and prescribe a 
liquid diet. Prescribe an enema each morning and evening for the 
next two days. On the day preceding the operation, it is a good idea 
to check peristalsis w^ith a small dose of opium. 





Fig. 640. — Making the first incision. (Veau.) Fig. 641. — Passing the first suture. {Veait. 



Employ general anesthesia. Carefully cleanse the peri-anal region 
and scrub the rectum with soap and water. Dilate the anus, as pre- 
viously described; and when the dilatation is complete the anal orifice 
wdll be everted more or less, presenting a ring of pile tumors. Fasten 
the pile tumor with a forceps, and at its lower end, make a short 
; curved incision (Fig. 640). The incision involves only the skin, 
which is to be loosened from the underlying structures by a little 
I blunt dissection. Suture this part of the skin before proceeding 
i further, using a small curved needle armed with a No. 2 catgut. 
Tie the suture moderately tight and leave the threads long for a 
50 



786 



DILATATION OF THE SPHINCTER ANI 



landmark, which will be appreciated later on. Pass two or three 
sutures in this manner, depending upon the length of the incision 
(Fig. 641). 




M. 




Fig. 642. — Freeing the veins by blunt 
dissection. (Veau.) 



Fig. 643. — Ligation of the first vascular 
pedicle. (Veau.) 





Fig. 644. — Burying the pedicle by Fig. 645. — Ligation of the last vascular 

suture. (Veau.) pedicle. (Veau.) 

Again prolong the incision on either side a little way and detach, 
by blunt dissection, the lips of the wound from the veins beneath, by 
which means a sort of pedicle is formed (Fig. 642). This pedicle 
consists of a part of the veins which are to be ligated and excised. 



OPERATION FOR PILES 



787 



Pass a ligature around a part of the veins (Fig. 643) and tie. Di- 
vide the ligated veins to the outer side and cut the ligatures short. 

Now pass a suture so as to enclose and cover in the stump 
(Fig, 644). 

Again prolong the original incision on each side of the base of the 
tumor and expose more of the pedicle; ligate, excise and suture as be- 
fore, until finally the upper pole of the tumor is reached, and the last 
of the pedicle tied off (Fig. 645). 

The terminal sutures enclose the last stump of the pedicle and com- 
plete the repair of the incision at the same time (Fig. 649). 





Fig. 646. — Applying the last suture. (Veau.) 



Fig. 647. — Treatment of ulcerated 
piles by cautery. {Veau.) 



It is better to proceed thus from below upward in order that the 
blood, always considerable, will flow downward and mask only the 
field already sutured. 

The line of incision must follow closely the base of the tumor, for 
if the edges of the wound are too widely separated, the strain may 
cause the sutures to tear out. 

If the whole of the anal circumference is involved, it is necessary to 
treat in the manner described the two sides only. 

Do not disturb the anterior and posterior poles of the anal border, 
although, if necessary, those points may be touched up with the 
thermo-cautery. 

Place drainage-tubes wrapped with iodoform gauze saturated in 
vaseline, as described under the head of Dilatation of the Sphincter. 



788 



DILATATION OF THE SPHINCTER ANI 






The subsequent pain is always severe and will require a hypoder- 
mic injection of morphine. Retention of urine is often present. 
The external dressings should be changed daily and liquid diet main- 
tained for five or six days and the bowels kept under restraint. Do 
not be concerned with the swelling. 

On the sixth day, remove the drainage-tube; on the seventh, open 
the bowels with castor oil or compound licorice powder, one heaping 




Fig. 648. — Laying open the track of fistula on the grooved director. (Veau.) 

teaspoonful every four hours till the bowels move, and instruct the 
patient to cleanse carefully the anal region after each movement. 

The sutures will be absorbed and if none give way too soon, the 
healing will be complete in about two weeks; otherwise there may be 
a raw surface which will need to be dressed a little longer. 

In certain cases there is no well-defined tumor, but the surface is 
ulcerated, infected and exceedingly painful, and is unaffected by pa- 
tient local treatment. 

In such a case, the thermo-cautery will probably give the best re- 
sults. For one or two days the patient is kept in bed and a moist 
dressing applied which will diminish the swelling. 

Employ general anesthesia, cleanse and dilate the anus. The 



OPERATION FOR PILES 789 

thermo-cautery is heated to a dull red. Pressed into the tumor, it 
loses its glow (Fig. 647). Reheat it and reapply a short distance 
from the point of application, and in this manner proceed until the 
pile has been well punctured. It is not necessary to puncture deeply. 
Apply drainage and a moist dressing. The subsequent pain is al- 
ways severe and must be controlled by a hypodermic of morphine. 
There may be retention of urine requiring relief by catheterization. 

, U •-• ' 

M /J/ f.lll,'X 







r/ 



Fig. 649. — Cauterization of the diverticula of the fistula. (Veau.) 

The dressing must be renewed twice daily. The eschar will drop off 
between the fourth and eighth day, and the bowels should be moved 
about the eighth day. The cure will be complete in about a month. 

OPERATION FOR ANAL FISTULA 

A grooved director is passed through the fistulous tract and emerg- 
ing in the rectum, its point is caught by the finger in the rectum and 
brought outside the anus. The whole length of the tract is laid open 
(Fig. 648). 

The diseased tissues are then curetted or touched with the cautery 
(Fig. 649). Pack with gauze until repair by granulation is complete. 



CHAPTER XXIV 

PHIMOSIS; PARAPHIMOSIS; CIRCUMCISION; 
HYDROCELE; CASTRATION 

PHIMOSIS 

Phimosis may be congenital or acquired, though it is much more 
frequently the former. There is usually present one or both of two 
conditions: a redundant prepuce with contracted orifice; or a frenum 
so short as not to permit retraction without marked bowing of the 
organ. 

The disturbances produced by congenital phimosis are due either 
to mechanical interference or reflex irritability, although, of course, 
many cases of phimosis • seem to give rise to the symptoms. The 
mechanical interference may lead to infection, balanitis, or even ure- 
thritis, or to straining which may be the origin of an inguinal or 
umbilical hernia; the straining may also produce prolapsus ani or 
hydrocele by pressure on the spermatic vessels. 

The reflex symptoms, often due perhaps to the adhesions of the 
prepuce to the glans, are numerous and varied, the most common be- 
ing disturbances of micturition, erethrism, and functional nervous 
derangements. 

Every case of phimosis, therefore, should receive attention in in- 
fancy, and in general the only treatment worth while is circumcision. 

The acquired phimosis of adult life, most often due to acute in- 
fective inflammations, is usually to be relieved by antiseptic washes 
and treatment addressed to the septic cause. 

PARAPHIMOSIS 

Paraphimosis has its origin in certain malformations, traumatism, 
or inflammations, and appears in many degrees of severity. In some 
causes it is easily reduced; in others, irreducible without an operation. 
There is always the danger, in severe and neglected cases, of ulcera- 

790 



PARAPHIMOSIS 



791 



tion, sloughing, or gangrene. The appearances are more or less con- 
stant: the exposed glans is swollen and reddened; behind it is a collar 
of congested mucous membrane; behind this a deep furrow in which 
lies the constricting band; and behind this, another band of swollen 
integument. 

An effort must be made at once to reduce the foreskin. The re- 
duction is always painful. Begin by thoroughly cleansing and cocain- 
izing the parts. Apply a compress saturated with a 20 per cent, 
solution of cocaine and then wait ten minutes. 

Smear a little vaseline on the balano-preputial furrow, but not over 
the glans generally, else the manipulating fingers will slip. 




Fig. 650. — Reducing a paraphimosis. {Stewart.) 

The purpose is to apply a slow, firm, and progressive pressure to the 
engorged tissues, at the same time making traction forward on the 
foreskin and pressure backward on the glans. 

There are several ways of doing this, of which the following is an 

' excellent method: grasp the penis behind the glans, between the first 

and second fingers of each hand, and while these make compression 

. and traction, the two thumbs are braced against the apex of the glans 

(Fig. 650). 

After reduction is accomplished, measures must be employed to 
subdue the inflammation and the patient advised of the necessity for 
a circumcision later to insure against a recurrence. 

If reduction cannot be accomplished by these measures, an opera- 
tion must be done without delay. The purpose is to divide the re- 
stricting band, which lies in the groove between the two ridges. 



792 



CIRCUMCISION 



Inject a little cocaine along the line of incision which is usually in 
the middle line of the dorsum and just behind the corona (Fig. 571). 

Use the point of the knife, making short, firm, shallow cuts, until 
the constricting band is felt to yield. A too bold incision may result 
in seriously wounding the corpora cavernosa. 




Fig. 651. — Dividing the constricting band in paraphimosis. (Veau.) 

The bleeding in any event will usually be free but ceases spontane- 
ously. The wound which at first was vertical, becomes transverse 
when reduction is completed, and is sutured in that direction. 

Apply a moist dressing and if there is no ulceration or gangrene, the 
swelling will soon subside. But in this case also the patient must be 
advised of the danger of recurrence unless a circumcision is done for 
the relief of the narrowed prepuce or the short frenum after the in- 
flammation has subsided. 

CIRCUMCISION 



This is an excellent operation probably not often enough done in 
infancy, when it is simple andjsvithout danger, and may prevent the 
disturbances of adolescence, consequent upon phimosis. 



CIRCUMCISION 



793 



In adult life it is often the primary step toward the relief of acute 
disorders and sexual irregularities. 

The Operation. — General anesthesia is nearly always indicated in 
children; local, in adults. To secure local anesthesia, begin by lightly 
tamponing the preputial orifice with a pledget of cotton saturated 
with a 10 per cent, solution of cocaine, and left in position for at least 
five minutes. Next inject the foreskin in the line of the proposed 
incision, using a 4 per cent, solution of cocaine or Schleich's solu- 
tion. The too rapid absorption of cocaine may be prevented by 
constriction of the base of the penis. 




Fig. 652. — Resection of the prepuce. (Veau.) 



When the anesthesia is established, break up the preputial ad- 
hesions with a grooved director or probe, usually not difficult in an 
infant but sometimes difficult in the adult, following balanitis. 

There are various methods of making the incision, any of which, 
properly employed, will give good results. Suppose the prepuce is 
long and slender: begin by holding the penis vertically and without 
making traction on the foreskin, apply a forceps so that its blades lie 
parallel with the oblique line of the corona (Fig. 652). Use care, of 
course^not to pinch the glans. Divide the foreskin with the bis- 
toury, allowing the blade to hug the upper side of the forceps, that no 
bruised tissues may be left behind. The skin retracts, leaving the 



794 



CIRCUMCISION 



mucosa covering the glans. Divide this mucous covering along the 
middle line to within % inch of the coronal border (Fig. 653). 
The glans will now be completely exposed. 

Trim off the two mucous flaps so that a narrow cuff is left. It is 
better to begin near the f renum and trim toward the terminal point of 
the dorsal incision (Fig. 654). If the f renum is too short, divide it 
transversely with the scissors (Fig. 655), catching up the little artery 
which will be divided. This completes the necessary incisions. 




Fig. 653. — Splitting the mucous membrane. (Veau.) 



Hemostasis must be assured. It may be necessary to tie two or 
three small vessels and nearly always the artery of the frenum re- 
quires ligation, using catgut No. 1. 

A brief application of adrenalin solution on a compress will check 
the oozing if it should persist. 

Suture. The mucous and cutaneous borders are brought into 
exact contact and united by several small, interrupted sutures of 
catgut (Fig. 656). The transverse incision of the frenum is made a 
vertical one by extending the glans, and is sutured in that direction 
(Fig. 657). 

In the case of children, it may be sufficient, instead of suturing, to 
use small clips, by which means, it is claimed, swelling is avoided. 

Dressing. — Wrap the penis in a sterile compress, leaving the glans 



CIRCUMCISION 



795 




Fig. 654.— Resection of the mucous mem- Fig. 655. — Section of the frenum. (Veau.) 
brane. (Veau.) 





r 



ig. 656. — Maintaining coaptation by means Fig. 657. — After section of the frenum the 
of a small clip. (Veau.) raw edges are coapted. (Veau.) 



h 



796 HYDROCELE 

exposed. Enclose the whole in a second compress perforated over 
the meatus, and secure with adhesive strips. 

Adults require bromides to prevent painful erections. The dress- 
ings are not to be changed unless soiled. Remove the sutures and 
re-dress the fifth day. It will probably require ten to twelve days 
for repair to be complete. 

Children usually need a daily change of dressing. If clips are 
used instead of sutures, they are to be removed at the end of twenty- 
four hours, and if the adjustment was perfect, the reunion by that 
time will often be practically complete. 

HYDROCELE 

The chief test of a hydrocele is its "translucency." The first 
treatment usually tried is tapping and the injection of an alterative. 
If the hydrocele recurs, then a radical operation should be done. 
Often this should be resorted to from the first without preliminary 
tapping, especially in the long-standing cases, where the tunica 
vaginalis is thickened and it is almost obvious that the trouble will 
recur. 

Occasionally the patient will prefer repeated simple puncture and 
evacuation without subsequent injection, rather than the more 
radical procedures which will lay him up for some days. 

Tapping. — -Anesthesia is not necessary. Prepare the field as for 
a surgical operation. Seize the tumor behind with the left hand so as 
to make it tense in front. The trocar, held in the right hand with 
index finger an inch from the point to limit its penetration, is entered 
with a sharp thrust into the middle and lower part of the anterior 
surface of the tumor (previously assure yourself that the testicle is 
not inverted). Withdraw the plunger, being careful that the tube is 
not displaced. When the fluid is evacuated, attach a syringe to the 
trocar and inject a drachm of a % per cent, solution of cocaine; 
gently massage the scrotum so as to bring the solution in contact 
with the whole testicle, wait ten minutes and then let the solution 
flow out. 

In the meantime charge the syringe with a drachm of pure tincture 



HYDROCELE 



797 



of iodine and inject. Hold it for five minutes and then let it escape. 
Withdraw the trocar and seal the puncture with collodion. 

The next day the scrotal wall is painful, reddened and swollen. 
The scrotum must be well supported, and moist compresses may give 
some relief. The patient should be kept in bed for ten days and 
warned that several weeks may be required for absorption of the 
exudates. 



: 



1 




Fig, 658. — Incision for hydrocele. (Veau.) 



RADICAL OPERATION 



1 



Sterilize the penis, scrotum, and perineum. Wrap the penis in a 
sterile compress and have it held out of the way. 

Local anesthesia may be employed, but a general anesthesia is 
better. 

Make an incision 2 inches long over the middle of the tumor, 
dividing first the several layers over the tunica (Fig. 658). Then 
ppen the tunica the whole length of the wound and evert the testicle. 
The tunica is stitched to the cord above and its free borders, brought 
together behind the epididymis, are to be sutured to each other 



79 8 



CASTRATION 



(Fig. 659). Or, the membrane may be resected completely, follow- 
ing close to the epididymis, and if the cut edges bleed, they are to be 
sewed with a continuous suture (Fig. 660). 

Restore the testicle, insert a small drain, and suture the scrotum. 
The drain should be removed on the second day and the sutures on 
the sixth, and in a day or two longer, the patient may get up. 




Fig. 659. — Everting the tunica vaginalis. (Veau.) 



CASTRATION 

The removal of the testicle is more frequently indicated as the 
result of cancer or tuberculosis, and may be done under either local 
or general anesthesia. 

The incision begins just below the external ring (on the right) 
and follows the direction of the cord for from 1% to 2 inches 
(Fig. 661). 

Expose and isolate the cord up to the inguinal canal which, if in- 
volved, should be opened, as in the operation for hernia. Separate 
the different elements of the cord, so as to require two or three sepa- 
rate ligatures. Do not include the cremaster in the ligatures 
(Fig. 662). Just below the catgut ligatures, resect the cord and enu- 
cleate the testicle from above downward (Fig. 663). 



CASTRATION 



799 




i ( iG. 666. — Hydrocele. Resection of the Fig. 66i. — Incision for castration. (Veau.) 

tunica vaginalis. (Veau.) 




Fig. 662. — Ligation of the spermatic cord. {Veau.) 



8oo 



CASTRATION 



This step is usually tedious in the tubercular cases on account of 
the adhesions which may have to be divided with the bistoury, and 
the bleeding points tied. 

Again inspect the cord (you have left the ligatures long till now) 
to be sure there is no bleeding; and it is recommended to cauterize 
the end of the vas in tuberculosis. 




Fig. 663. — Separating the testicle from the scrotal tissues. (Veau.) 

Repair first the inguinal canal, if it was opened. Insert a drain- 
age-tube reaching to the bottom of the scrotum and projecting from 
the upper angle of the wound which is the point least likely to get 
infected after the dressings are applied. The tubercular cases espe- 
cially require drainage. Suture and apply a dry dressing. Remove 
the tube on the third and the sutures on the sixth or seventh. 






CHAPTER XXV 

INGROWING TOE-NAIL 

The particular point in this operation is to obliterate the matrix 
corresponding to the part of the nail removed. It is insufficient to re- 
move only that part of the nail gouging the flesh. Usually one side 
only is involved, the outer side, and the removal of half the nail will 
effect a cure. 




Fig. 664. — Local anesthesia. (Veau.) 

Employ local anesthesia. Constrict the base and make a circular 
injection of cocaine or stovaine (Fig. 664). 

Remove the Nail. Introduce the sharp point of the scissors under 
the nail and divide its entire length (Fig. 665). Next seize the dis- 
eased portion with a forceps and tear it out (Fig. 666). 

Extirpate the Matrix. Incise the integument of the matrix to be 
eliminated, with a sharp-pointed bistoury, holding the cutting point 
51 801 



802 



INGROWING TOE-NAIL 





Fig. 665. — Splitting the nail. {Veau.) Fig. 666. — Wrenching the nail out. {Veau. 





Fig. 667. — Incision over the matrix. {Veau.) Fig. 668. — Extirpation of matrix. {Veau.) 



INGROWING TOE-NAIL 



803 



obliquely, so that it gets a larger bite deeply than superficially (Fig. 
667). The soft parts are thus removed down to the bone (Fig. 668). 
A deep cavity is left in the bottom, of which the bone may be seen 
(Fig. 669). This cavity should be packed with sterile gauze and 





A.M 



Fig. 669. — The matrix removed. (Veau.) 



Fig. 670. — -Wound sutured. (Veau.) 



allowed to heal by granulation, which will require two or three weeks. 
It is advisable to diminish the size of the cavity by a suture, including 
on one side the skin, and on the other, the subungual tissues (Fig. 
670). It will probably give way finally, yet it facilitates repair. 



CHAPTER XXVI 

REMOVAL OF SMALL TUMORS 

The technic for the removal of small tumors on or under the skin 
should be kept in mind. As in more difficult operations, a definite 
procedure should be followed. A lack of system may make a minor 
matter one of difficulty. 

Local anesthesia will usually suffice. It should be complete. To 
secure a complete local anesthesia, begin by determining the lines of 
incision, and along these lines inject a 2 per cent, solution of CO- 





rf ,# 



'*# 



Fig. 671. 



-Anesthesia of the skin. 
{Veau.)\ 



Fig. 672. 



-Anesthesia of the deeper layers. 
(Veau.) 



caine; intradermic, not subcutaneous. If the tumor is large or if the 
skin is loose, redundancy may be avoided by making two semicircu- 
lar incisions, thus removing an ellipse of the skin (Fig. 671). 

Next loosen the edges of the skin and partially expose the tumor 
and make a new injection along its sides. Later inject the base of the 
tumor as the dissection proceeds (Fig. 672). 

In the case of sebaceous cysts, the main point is to remove the sac in 
its entirety ; anything else insures a return of the trouble. If possible, 

804 



REMOVAL OF SMALL TUMORS 



80 s 



dissect the sac out without emptying its contents. The dissection 
will be done with ease only in case all the layers are incised down to 
the true capsule. If the cyst walls are particularly thick, the contents 
may be emptied out from the first. 

Once the cyst is exposed retract one lip of the skin wound and 




Fig. 673. — Detaching the capsule. (Veau.) 




Fig. 674- — Dissecting a loose capsule with the bistoury. (Veau.) 

loosen the attachments by blunt dissection (Fig. 673). Or if the 
fibrous attachments are loose and tough, divide them with scissors or 
scalpel (Fig. 674). 

There will be some slight hemorrhage from the cavity following 
the removal of the cyst, but it will be easily controlled by pressure or 
by a hot compress. In case the cyst was emptied in the course of the 



806 REMOVAL OF SMALL TUMORS 

operation, be assured that all the cyst wall is removed, or the growth 
will recur. 

The procedure is the same in the case of a fatty tumor unless it is 
pedunculated; if so, make a curved incision on each side of its base. 
Usually a small blood vessel at the base of the tumor will require 
ligation. 

Synovial cysts require special attention to asepsis or the cavity with 
which they are connected, and from which they originate, may be- 
come infected; thus an arthritis or teno-synovitis might develop. 
The pedicle requires careful ligation. 

Branchial cysts are often intimately connected with the vessels in 
the neck and their dissection may be extremely difficult. The pedicle 
of such cysts usually terminates in the thyro-glossal duct. 

Angiomas are likely to give rise to dangerous hemorrhage. Only 
such as are small and well defined should be undertaken by the prac- 
titioner. No effect should be made to enucleate; instead elliptical 
incisions should be made quite beyond the borders of the tumor and 
the whole removed u en masse" Usually a well-defined vascular 
pedicle will require careful ligation. 



CHAPTER XXVII 

SKIN GRAFTING 

Skin grafting is a measure deserving to be more generally employed 
by the practitioner. Very often it would save time and trouble in the 
treatment of those conditions in which epidermitization is long de- 
layed, for this it hastens and also it tends to prevent the formation of 
scar tissue. Thus chronic ulcers, burns, and lacerated wounds fol- 
lowed by extensive sloughs may require grafting. 

The operation is simple in theory yet attended by many failures 
through lack of attention to detail. 

Three factors require the minutest supervision: (i) the field must 
be properly prepared; (2) the grafts must be cut correctly; (3) the 
after-treatment must be appropriate. 

(1) The area to be grafted must be sterile and must be free of any 
oozing. If an ulcer is to be treated, the granulations must previously 
be made as healthy as possible: if sluggish, by currettement; if exuber- 
ant, by touching up with nitrate of silver. A few days afterward it 
will be ready to receive the graft. A dry sterile dressing should be 
applied a day previous to the operation; before the graft is applied, 
the surface should be thoroughly douched with normal salt solution. 

(2) The skin which is to furnish the graft should be shaved and 
thoroughly scrubbed with soap and water. Antiseptics had better 
be avoided for they may compromise the vitality of the cellular ele- 
ments. A sufficient anesthesia may be obtained by injection of 
Schleich's solution No. 3. 

Two methods of cutting the grafts are currently employed, Rever- 
din's and Thiersch's. 

(I) Rtverdin's Method. — A small fold of the skin is picked up with 
fine tissue or mouse-toothed forceps and cut off at its base with small 
pointed scissors (Fig. 675). This section includes practically all the 
layers of the skin (Fig. 676). The graft is applied and gently pressed 

807' 



8o8 



SKIN GRAFTING 



out. Fifteen or twenty points are thus placed about 15 mm. or 
say % inch apart. If the surface is large enough to require more, the 
center should be left bare and treated by a second operation (Fig. 
677). 





Fig. 675. — Manner of cutting the 
Reverdin graft. (Veau.) 



Fig. 676.— The graft 
removed. {Veau.) 



(II) Thiersch's Method. — This method is the better when it suc- 
ceeds, but the conditions of success are more exacting. Granulation 
tissue usually needs to be removed by currettement, exposing the 




Fig. 677.— Placing Reverdin grafts. Ulcer of leg. {Veau.) 

fibrous layer. The edges of the ulcer must be scraped (Fig. 678). 
The oozing which follows must be completely checked. A firm com- 
press applied for ten or fifteen minutes will usually suffice. If oozing 
persists, the operation will fail. 



SKIN GRAFTING 



809 



The grafts in this case consist of thin slices of the epidermis, as long 
as necessary and as wide as convenient. They are usually taken 




Fig. 678.- — Thiersch's method. Preparing the wound for the graft. (Veau.) 

from the anterior surface of the thigh. A sharp, thin-bladed razor 
, is used in cutting the slice (Fig. 679). 




Fig. 679. — Cutting the Thiersch graft. (Veau.) 

The skin must be put on the stretch. Special retractors are occa- 
sionally employed. The two hands of the assistant and the left hand 



8io 



SKIN GRAFTING 



of the operator can make it sufficiently tense (Fig. 680). The razor 
is held nearly horizontally and cuts by a rapid, short, sawing motion. 
As the razor progresses, the thin and pliable tissue piles up on the 
blade. 

The graft is now applied to the raw surface and the free end fixed 
by a pointed instrument and slowly worked of the blade, and then 
teased out flat (Fig. 681). 




Fig. 680. — Cutting the Thiersch graft. (Veau.) 



So proceed until the whole surface is covered. Small angles may 
be filled in with Reverdin grafts (Fig. 682). The area denuded need 
only to be covered with a sterile dressing and repair will soon be 
complete. 

(3) The grafted area must be carefully covered with strips of 
rubber tissue or gutta-percha, placed in various directions so as to 
hold the grafts in place and at the same time give exit to any exudates. 
A layer of gauze saturated with salt solution is next applied, which in 



SKIN GRAFTING 



8ll 



turn is covered by absorbent cotton, and the whole held in place by a 
moderately firm bandage. 





Fig. 68 i. — Method of applying the 
graft. (Veau.) 



Fig. 682. — Wound covered by- 
grafts. (Veau.) 



The part shoulji be immobilized, employing plaster splints if 
necessary. Change all the dressings except the rubber tissue every 
day or two and douche gently with normal salt solution. At the 
end of a week or ten days, change the tissue. 






INDEX 



Abdomen, contusions, 125 

gunshot wounds, 151, 171, 219 

incised wounds, 130 

injuries, 125 

laparotomy, 131 

non-penetrating wounds, 127 

penetrating wounds, 129 

punctured wounds, 129 

stab wounds, 129 
Abdominal drainage, 131 

hemorrhage, 533 

section, 531 
ibducens nerve, 396 
Ibscess, acute, 375 

alveolar, 384 

anal, 403 

antrum, mastoid, 527 

appendicial, 571 

axillary, 395 

Bartholin's gland, 410 

breast, 393 

cervical glands, 392 

chronic, 378 

definitions, 375 

dental, 384 

drainage, 377 

external auditory meatus, 382 

eyelids, 381 

face, 380 

floor of the mouth, 386 

iliac, 418 

ischio-rectal, 400 

kidney, 552 

labium, 410 

lachrymal, 382 

liver, 414 



Abscess, lung, 502 

mammary, 393 

mastoid, 522 

nasal septum, 381 

palmar, 398 

parotid, 382 

pelvic, 411 

peri-anal, 403 

perineal, 404 

plantar, 400 

popliteal, 398 

prostatic, 404 

psoas, 418 

rectal, 403 

retropharyngeal, 389 

scalp, subaponeurotic, 379 
subperiosteal, 380 
superficial, 379 

seminal ducts, 408 

submammary, 385 

submaxillary, 385 

subphrenic, 414 

symptoms of, 375 

tongue, 388 

tonsillar, 388 

treatment, acute, 376 
chronic, 378 

urinary, 712 

vulvar, 409 

vulvo-vaginal, 410 
Accidents, anesthesia, 16 
Actual cautery, phlegmon, 430 
Acupressure, 61 
Acute intestinal obstruction, 577 

retention of urine, 698 
Adrenalin chloride, anesthesia, 16 



813 



814 



INDEX 



Adrenalin chloride, epistaxis, 68 

gauze tape, 64 

shock, 55 
Air passages, foreign bodies, 459 

burns, 472 
Alcohol, antisepsis, 3 
Allison, strangulated hernia, 609 
Alveolar abscess, 384 
Ammonia after anesthesia, 18 
Amputations, arm, 749 

Chopart, 765 

elbow, 748 

finger, 730 

foot, 767 

forearm, 745 

general technic, 728 

great toe, 761 

hand, 745 

hip -joint, 778 

index finger, atypical, 736 

knee-joint, 775 

leg, 772 

little ringer, 735 
toe, 762 

metacarpal, 739 

metatarsal, 764 

middle ringer, 733 
toes, 762 

PirogofFs, 769 

principles, 728 

Syme's, 770 

thigh, 777 

thumb, atypical, 744 
typical, 738 

toes, 760 

scapulo-humeral, 759 

shoulder, 749 
Anal abscess, 403 

dilatation, 783 

fistula, 789 
Anastomosis, intestinal, 650 
Andrews, Colles' fracture, 245 
Anesthesia, 12 

accidents, 16 

ammonia, 18 



Anesthesia, chloroform, 12 

cocaine, 18 

ether, 14 

ethyl chloride, 18 

local, 18 

spinal, 22 

stovaine, 19 

vomiting, 17 
Anesthetics, 3 
Aneurism, gunshot, 138 
Aneurismal varix, 138 
Angina, Ludwig's, 386 
Angiomas, 806 
Angus, torsion, 671 
Ankle amputation, 769 

arthrotomy, 446 

dislocation, 336 

fracture, 276 

sprain, 343 
Anterior crural nerve, exposure, 367 

injury, 366 
Anterior tibial artery, ligation, 725 

nerve, injury, 371 
Antipyrine, epistaxis, 68 
Antisepsis, emergency, 6 
Antiseptics, 3 
Antitetanic serum, 199 
Antistreptococcic serum, phlegmon, 

431 

Antrum, mastoid, 522 
Anus, abscess, 403 

artificial, permanent, 593 
temporary, 589 

dilatation, 783 

fistula, 789 

imperforate, 662 

piles, 784 
Appendectomy, 563 
Appendicial abscess, 571 
Appendicitis, 557 

after-treatment, 574 

catarrhal, 559 

diagnosis, 557 

gangrenous, 561 

operation, 567 



INDEX 



815 



I 



Appendicitis, perforating, 561 
treatment, 563 
ulceration, 561 
varieties, 560 
Appendix in hernia, 615 
Arm, amputation, 749 
bandages, 45 
fractures, 209 
phlegmons, 429 
Army bullet, 135 
Aristol in burns, 471 
Arrest of hemorrhage, 60 
Arterial hemorrhage, 57 
Arteries, ligations, rules, 717 
suture, 717 
torsion, 62 

wounds, gunshot, 138 
Artery forceps, 4 

ligation, anterior tibial, 725 
axillary, 722 
brachial, 722 
common carotid, 719 
compression, 66 
dorsalis pedis, 726 
external carotid, 720 
femoral, 724 
lingual, 720 
obturator, 368. 
posterior tibial, 726 
radial, 723 
subclavian, 720 
ulnar, 724 
Artificial anus, permanent, 593 
temporary, 589 
limbs, 772 
respiration, 17 
Arthritis, septic, 440 
Arthrotomy, 441 
ankle, 446 
elbow, 447 
hip, 448 
knee, 441 
shoulder, 448 
wrist, 448 
Arx, heart injuries, 125 



Asphyxia, anesthesia, 16 

foreign bodies, 456 

retropharyngeal abscess, 389 
Aspiration, bladder, 707 

pericardium, 498 

pleura, 504 
Astragalus, dislocation, 336 

fracture, 280 
Auditory nerve, injuries, 359 
Automatic centers, paralysis, 13 
Axillary artery, ligation, 722 

abscess, acute, 395 
chronic, 395 
Axtell, wound of chest, 119 

trephining, 520 

Bandage, arm, 45 
Barton's, 47 
breast, 44 
eye, 47 
finger, 44 
foot, 38 
groin, 41 
hand, 45 
head, 47 
knee, 41 

neck, 45 

shoulder, 45 

St. Andrew's cross, 44 

stump, 48 

thumb, 45 
Bandages, 37 

method of applying, 38 

plaster, 49 
Bartholin's gland, abscess, 410 
Barton's bandage, 47 
Base of thorax, wounds, 120 
Bassini, operation for hernia, 

632 
Bavarian splints, 51 
Belfield, drainage of seminal ducts, 

408 
Bellocq's cannula, 69 
Bennett, Sir W., torsions, 670 



8i6 



INDEX 



I 



Bennett's fracture, 247 

Biceps tendon dislocation, 347 

Bi-coude catheter, 699 

Bier treatment, 424 

"Black eye," 382 

Bladder, aspiration in retention, 

707 
Bladder, cystotomy, 708 

foreign bodies, 467 

hernia operation, 614 

gunshot wounds, 153 

puncture, 707 

rupture, 553 

suture, 555 

wounds, 554 
Blank cartridges, 198 
Bleeding (see Hemorrhage) 
Bloodgood, intestinal obstruction, 

577 

fractures, 203 
Blood vessels, injuries, 92, 95 
Bolo wounds, 173 
Bone plating, 275 

wiring, 234 
Bonney, emergency operations, 6 
Bowel, acute obstruction, 577 
Bowls, sterilization, 9 
Brachial artery, compression, 66 

ligation, 722 
Brain, abscess, 166 

compression, 306 

concussion, 304 

contusion, 306 

gunshot wounds, 146, 166 

hemorrhage, 510 

injuries, 299 

topography, 510 
Branchial cysts, 806 
Breast abscesses, 393 

bandage, 44 
Brickner, tubal pregnancy, 676 
Bronchi, foreign bodies, 459 
Bronchoscopy, Killian, 461 
Brown, Cesarean section, 684 
Bruises (see Contused wounds) 



Brushes, hand, 2 

Bryant, esophagotomy, 486 

vertical extension, 262 
Bullet wounds, civil, 186 

military, 133 
Bullets, types, 135 
Burmeister, preparation of the 

hands, 10 
Burns and scalds, 468 
Burns, air passages, 472 
Burns, electrical, 473 
Burns, mouth, 472 

Cahill, torsions, 670 

Calmette's antitetanic powder, 

199 
Cannaday, subcuticular suture, 

3i 

Capitellum, 46 
Carbuncle, 381 
Carotid artery compression, 66 

ligation, 719 
Carpus, dislocation, 342 

fracture, 246 
Carron oil, 472 
Castration, 798 

emergency, 107 
Catgut, 26 

chromicized, 26 
Catheterization, equipment, 699 

retrograde, 695 
Catheters, acute retention, 699 

box for, 4 

sterilization, 699 
Cecum in hernia, 613 
Cerebro-spinal fluid, charact 

300 
Cervical glands, suppuration, 392 
Cesarean section, 682 
Championniere, fractures, 205 
Charlton, foreign body in bladder, 

467 
Chest contusions, 114 

wounds, no 
Cheyne, phlegmon of neck, 431 




INDEX 



817 



Chipman, reduction of shoulder, 

321 
Chloral, wounds of tongue, 85 
Chloroform anesthesia, 12 

face in, 13 

pulse in, 13 

pupil in, 13 
container, 13 
Chopart's amputation, 765 
Cigarette drain, 33 
Circular enterorrhaphy, 654 
Circumcision, 792 
Circumflex nerve, exposure, 366 

injury, 366 
Clavicle, fracture, 290 
Cocaine, 4 

anesthesia, 18 
Coley, femoral hernia, 569 
Collapse, 53 
Colles' fracture, 242 
Colon bacillus, 557 
Colostomy, 593 
Colpotomy, 348, 411 
Combs, foreign body in rectum, 

.464 

Comminuted fractures, 168, 200 
Compound dislocations, 338 

elbow, 340 

hip, 340 

knee, 342 

shoulder, 340 

wrist, 342 
fractures, 283 

ankle and foot, 288 

tibia, 286 
Compression of arteries, brachial, 66 

carotids, 66 

coronary, 66 

facial, 66 

femoral, 67 

intercostals, 68 

occipital, 66 

plantar, 68 

popliteal, 67 

subclavian, 66 






Compression of arteries, temporal, 66 
tibial, 67 
ulnar, 66 

of brain, 304 
Concussion of brain, 304 
Condyles of humerus, fracture, 230 
Congenital hernia, 632 
Coin catchers, 457 
Conjunctiva, foreign bodies, 451 

wounds, 91 
Continuous suture, 27 
Contusions, ^2 

abdomen, 125 

brain, 306 

chest wall, 114 

eye, 89 

eyelid, 86 

knee-joint, 342 

lung, 114 

nerves, 358 

scalp, 81 

urethra, 689 
Cook, appendicitis, 564 
Cooper, reduction of elbow, 328 
Coracoid process, examination, 215 
Corner, torsions, 674 
Coronary artery, compression, 66 
Cotton, injuries to testicle, 108 
Cradle splint, 164 
Cranial nerves, injuries, 359 
Craniectomy, emergency, 510 
Crepitus, 201 
Crile, direct transfusion, 55 

shock, 55 
Crucial ligaments, rupture, 345 
Crushing injuries to the extremities, 

97 

Cullen, torsions, 674 
Cushing, shock, 56 
Cut throat, 86 

wrist, 91 
Cystotomy operation, 695, 708 

Dayat, foreign bodies, 466 
Deep epigastric artery, 68 



8i8 



INDEX 



Dental abscess, 384 
Depressed fracture, skull, 302 
Diaphragm, wounds, 122 
Digital arteries, compression, 67 
Dilatation of the anus, 783 

urethral stricture, 701 
Direct pressure in hemorrhage, 

60 
Dislocations, 312 

ankle, 336 

compound, 338 

elbow, 327 

finger, 330 

hip, 330 
jaw, 326 
knee, 334 
patella, 336 
shoulder, 312 

after-treatment, 325 
subclavicular, 316 
subcoracoid, 312 
subglenoid, 322 
subspinous, 324 
semilunar cartilages, 335 
thumb, 329 
wrist, 340 
Dixon, tubal pregnancy, 676 
Dorsalis pedis artery ligation, 

726 
Dorsum ilii, dislocation, 330 
Double spica, 37 
Downey, fracture of femur, 260 
Doyen's trephine, 514 
Drainage, 32 

abdominal, 131 
abscess, 377 
accidental wounds, 32 
amputations, 728 
appendicitis, 571 
arthrotomy, 442 
aseptic wounds, 32 
cigarette, 33 
compound fractures, 34 
empyema, 508 
gauze wick, 33 



Drainage, heart wounds, 495 

operative wounds, 34 

tubes, 33 

urinary infiltration, 716 
Dressings, 35 

first aid, 153 

frequency, 36 
Dupuytren's splint, 279 
Dura mater, wounds, 517 
Dutch cane splints, 48 
Dyspnea, heart wounds, 123 

Ear drum, paracentesis, 523 
forceps, 453 
foreign bodies, 452 
Eastman, J. R., hernia, 640 

intestinal obstruction, 578 
Eastman, T. B., appendicitis, 558 
Ectopic gestation, 675 
Edema of glottis, 483 
Elbow, amputation, 748 
arthrotomy, 447 
dislocation, 327 
fracture, 230 
gunshot wounds, 159 
wound, 95 
Electrical burns, 473 

shock, 473 
Elliott, wounds of kidney, 553 
Emergency antisepsis, 6 

operations, preparation, 7 
surgery, equipment, 2 
military, 185 
Emphysema, chest injuries, 113 
Empyema of thorax, 502 
adult, 506 

after-treatment, 509 
child, 505 
diagnosis, 502 
puncture for, 504 
Enemas, technic, 580 
Enterectomy, 650 
Enterorrhaphy, 653 
Enterostomy, 589 
Epistaxis, 68 



INDEX 



819 



Equipment, emergencies, 2 
Esophagotomy, 484 
Esophagus, foreign bodies, 455 

wounds, 89 
Estes, intussusception, 583 
Ether anesthesia, 14 

adrenalin chloride in, 15 
External auditory meatus abscess, 
382 

carotid artery ligation, 720 

urethrotomy, 691 
Extravasation of urine, 712 
Extremities, crushing injuries, 97 

fractures, 200 

wounds, 92 
Eye bandage, 47 

foreign bodies, 451 

injuries, 89 
Eyelid, abscess, 381 

contusion, 86 

wounds, 86 

Face, abscesses, 380 
fractures, 299 
furuncle, 380 
gunshot wounds, 169, 190 
wounds, 84 
Facial artery, compression, 66 
ligation, 720 
nerve injuries, 359 

mastoid operation, 528 
Felon, 423 

Femoral artery, compression, 67 
ligation, 724 
stab wound, 95 
hernia, anatomy, 617 
radical cure, 643 
strangulated, 617 
operation, 619 
taxis, 603 
Femur, amputations, 777 
fractures, 252 

after-treatment, 260 
children, 262 
epiphyseal, 262 

\i 



Femur fractures, shaft, 257 
supracondylar, 260 

osteomyelitis, 438 
Fibula, fractures, 276 
Field of operation, sterilization, 

10 
Figure-of-eight bandage, 38 
Fingers, amputations, 731 

bandages, 44 

dislocations, 330 

fractures, 247 

infections, 422 
First aid, dressing, 153 

fractures, 208, 251 

hemorrhage, 65 

splints, 180 
Fiske, wounds of spleen, 551 
Fistula, anal, 789 

urinary, 712 
Fitzmaurice-Kelley, amputation for 

shell wounds, 156 
Floor of mouth, abscess, 386 
Florschiitz suspension, 165 
Foot, amputations, 767 

bandages, 38 

fractures, 280 + 

Forceps, artery, 5 

aural, 453 

nasal, 455 

urethral, 465 
Forcipressure, 61 
Ford, ether anesthesia, 16 

fracture of patella, 265 
skull, 419 
Forearm, amputation, 745 

phlegmon, 427 
Foreign bodies, air passages, 459 

bladder, 467 

ear, 452 

esophagus, 455 

eye, 451 

larynx, 459 

nose, 454 

pharynx, 455 

rectum, 462 



820 

Foreign bodies, trachea, 459 

urethra, 465 
Fountain syringe, 3 
Fowling piece, gunshot wound, 
Fox worthy, bolo wounds, 173 
Fractures, 200 

ankle, 276 

anterior tuberosity of tibia 

arm, 209 

astragalus, 280 

carpus, 246 

clavicle, 290 

Colles', 242 

compound, 283 

condylar, 230 

crepitus, 202 

definitions, 200 

diagnosis, 201 

elbow, 230 

extremities, 200 

face, 299 

gunshot, 169, 190 

femur, 252 

gunshot, 169, 190 

fibula, 276 

fingers, 247 

first aid, 208 

foot, 280 

forearm, 237 

gunshot, 155, 159 

hand, 246 

head, 301 

humerus, 209 

immobilization, 205 

intercondylar, 232 

jaw, lower, 309 
upper, 308 

leg, 270 

lower extremities, 251 

malar, 308 

maxillae, 180, 308 

metacarpus, 246 

nasal bone, 309 

olecranon process, 233 

os calcis, 281 



INDEX 







Fractures, pain, 202 

patella, 264 

pelvis, 297 
198 Pott's, 276 

prognosis, 201 

radius, 237 
head, 236 
, 276 lower end, 241 

reduction, 204 

ribs, 295 

scapula, 294 

skull, 299 

compound, 303 

spine, 296 

splints, 207 

supracondylar, 225 

tarsus, 280 

thumb, 247 

tibia, 269 

toes, 282 

treatment, 204 

ulna, 237 

vertebra, 296 

wrist, 246 
Freezing, 474 
Frost bite, 475 
Furuncle of face, 380 
Fysche, gunshot wound, 193 

Gage, rupture quadriceps extensor, 

350 

Gangrene, amputation, 728 
Garrison, emergency operations, 6 
Gastric lavage, 14, 16, 580 
Gastro-enterostomy, 478 
Gauze, 4 

drainage, 33 

dressings, 35 
General practitioner as emergency 

surgeon, 1 
Genito-crural nerve injury, 369 
Gerster, treatment of peritonitis, 

576 

Gibbon, suture of heart, 495 
Gloves, rubber, 10 



INDEX 



821 



Gooch's splint, 48 

Gosset, wounds of nerves, 139 

Granger, burns, 472 

Great toe, amputation, 761 

Groin, bandage, 41 

Groves, gunshot fractures, 157 

Guibal, subphrenic abscess, 414 

Gunshot fractures, 155, 159 

t wound of abdomen, 151,171, 
bladder, 153 
blood vessels, 138 
bone, 144 
brain, 146, 166 
cranium, 145, 166 
face, 169, 190 
fascia, 138 

I hand, 197 

head, 187 
heart, 151 
intestine, 152 
joints, 145, 166, 195 
kidney, 153 
knee, 166, 195 
liver, 153 
lungs, 150 
muscles, 138 
neck, 169 
nerves, 139 
pancreas, 153 
rectum, 153 
skin, 137 
skull, 144, 167 
spine, 148, 170, 189 
spleen, 153 
stomach, 152 
thorax, 149, 171, 196 
trachea, 170 
wounds, civil, 186 
effects on tissues, 137 
hemorrhage, 137 
military, 137 
prognosis, 153 
shock, 137 
suicidal, 188 
treatment, 153 



Gun-splint, 184 

Guyon, catheterization, 705 

Hand, abscess, 424 

amputations, 745 

bandages, 45 

brushes, 2 

fractures, 246 
192 gunshot wound, 197 

infections, 424 

injuries, 100 

sterilization, 9 
Harrington's solution, 10 
Harsha, torsions, 670 
Hartmann, splenectomy, 673 
Havard, gunshot wounds, 152, 172 
Haynes, wounds of liver, 548 
Head wounds, 81 

bandages, 47 
Heart, gunshot wounds, 151 

massage, 17 

repair, 490 

suture, 495 

wounds, 122 
Heile, treatment of ileus, 587 
Hemarthrosis, 166, 197 
Hematoma, 72 
Hematuria, 552 
Hemopericardium, 114 
Hemopneumothorax, 112 
Hemoptysis, in 
Hemorrhage, 57 

acupressure, 61 

adrenalin chloride, 58 

arrest, 60 

arterial, 57 

capillary, 57 

chemicals in, 60 

constitutional effects, 57 

definitions, 57 

diagnosis, 58 

ectopic gestation, rupture, 675 

fatal, 58 

first aid, 65 

forcipressure, 62 



822 



INDEX 



Hemorrhage, heat, 60 

hypodermoclysis, 59 

infusion, intravenous, 59 

intermediary, 57 

internal, 57 

kidney, 541 

laparotomy, 532 

liver, 541 

meningeal, 301 

mesentery, 541 

normal salt solution, 59 

operative, 60 

parenchymatous, 57 

primary, 57 

secondary, 57 

spleen, 541 

spontaneous arrest, 60 

symptoms, 57 

torsion, 62 

tourniquets, 61 

treatment, 58 

tubal pregnancy, 675 

venous, 57 
Hemorrhoids, operations, 784 
Hemostasis, 60 
Hemothorax, 111 
Hennequin's dressing, 211 
Hernia, appendix, 615 

bladder, 614 

cecum, 613 

encysted, 613 

femoral, 643 

gangrenous, 609 

inguinal, 632 

interstitial, 614 

lumbar, 631 

lung, 113 

obturator, 628 

ovaries, 631 

perineal, 631 

preperitoneal, 614 

radical cure, femoral, 643 
inguinal, 632 
umbilical, 626 
vaginal, 631 



Hernia, sciatic, 631 

septic absorption, 598 

sigmoid, 613 

stomach, 617 

strangulated, 598 

umbilical, 622 
Hernial sac, anomalies, 613 
Hernio-laparotomy, 613 
Hertzfeld, epistaxis, 69 
Heyvrosky, bullet wound of blood 

vessels, 138 
Hilton, abscess, 396 
Hip-joint, arthrotomy, 448 

amputations, 778 

dislocations, 330 

gunshot wounds, 166 
Hodgen's splint, 262 
Holliday, splenectomy, 550 
Humerus, fractures, 209 

anatomical neck, 220 

external condyle, 229 

greater tuberosity, 221 

gunshot, 157 

internal condyle, 230 

lower end, 222 

osteomyelitis, 437 

shaft, 209 

supracondylar, 225 

surgical neck, 216 

upper end, 213 
in children, 221 
Hunt, tubal pregnancy, 681 
Hyde, foreign body in urethra, 467 
Hydrocele, 796 

radical operation, 797 

tapping, 796 
Hypodermoclysis, 59 
Hysterectomy, 681 

Ice, appendicitis, 563 
Ileus, post-operative, 586 
Iliac abscess, 418 
Ilio-inguinal nerve injury, 369 
Imperforate anus, 662 
Incised wounds, 73 






INDEX 



823 



Incised wounds of elbow, 95 
of neck, 88 
of wrist, 92 
Index finger, amputation, 735 
Infected wounds, 79 
Infections, acute, 421 
Inferior maxilla fracture, 309 
Infiltration of urine, 712 
Ingrowing toe-nail, 801 
Inguinal hernia, anatomy, 632 
radical cure, 632 
strangulated, 598, 603 
Injuries, abdomen, 125 
hand, 107 
joints, 312 
nerves, 357 
thorax, no 
Instruments, emergency, 5 
cleansing, 5 
preparation, 7 
Intercondylar fractures, 232 
Intercostal artery, hemorrhage, 68 
Internal mammary artery, 68 
Interrupted sutures, 29 
Interstitial hernia, 614 

tubal pregnancy, 679 
Intestinal anastomosis, 650 
end to end, 654 
lateral, 657 - 
Murphy button, 656 
termino -lateral, 660 
obstruction, acute, 577 
gastric lavage, 580 
laparotomy, 581 
rectal enema, 580 
symptoms, 578 
treatment, 579 
resection, 651 
rupture, 127 
Intestines, suture, 543 

wounds, 541 
Intracranial hemorrhage, 510 
Intravenous infusion, hemorrhage, 

59 
shock, 55 



Intravenous infusion, technic, 59 
Intussusception, 582 

operation for, 585 
Iodine, sterilization of the skin, 10 
Irrigator, 3 

Ischiatic dislocation, 331 
Ischio-rectal abscess, 400 

Jaw, dislocation, 326 

fracture, 308 
gunshot, 169 
Joints, contusions, 342 

dislocations, 312 
compound, 338 

gunshot wounds, 145, 166 

hemorrhage into, 146, 167 

incised wounds, 343 

injuries, 312 

punctured wounds, 342 

sprains, 282, 343 

stab wounds, 342 

suppurations, 440 
Jonnesco, spinal anesthesia, 23 

Keen, Cesarean section, 684 
Kelley, torsions, 667 
Kidney, abscess, 552 

hemorrhage, 541 

injuries, 552 

removal, 552 

rupture, 552 

wounds, 552 
Killian, bronchoscopy, 461 
King, fracture of extremities, 201 
Knott, suture of liver, 548 
Kocher, shoulder dislocation, 313 
Kollman, filiform guide, 703 
Konig, preparation of the skin, 10 
Knee, amputation, 775 

arthrotomy, 444 

bandage, 41 

contusions, 342 

crucial ligaments, 345 

dislocations, 334 

gunshot wounds, 146, 167 



824 INDEX 



Knee, puncture, 445 

sprains, 343 

stab wounds, 342 

wounds, 342 
Kutner, wounds of lung, 192 
Kyle, foreign body in nose, 455 

Labium, abscess, 409 
Lacerated wounds, 77 
Laceration of brain, 299 
Lachrymal abscess, 382 
Lanphear, Cesarean section, 683 
Laparotomy for Cesarean section, 
682 

general technic, 530 

gunshot wounds, civil, 186 
military, 133 

intestinal obstruction, 579 

for traumatism, 537 
Laplace, peritonitis, 576 
Laryngotomy, 484 
Larynx, foreign bodies, 459 

wounds, 88 
Lateral anastomosis, intestine, 657 

sinus thrombosis, 523 
Lavage, gastric, 151, 580 
Leg, amputations, 772 

bandage, 41 

fractures, 269 

osteomyelitis, 435 
Lejars, appendicitis, 563 

preparations for operation, 7 

reduction of shoulder, 313 
thumb, 329 

rupture of the lung, 115 

splint for leg, 272 
Lembert suture, 544 
Lichtenstern, torsion, 673 
Ligation, 62 
Ligation en masse, 63 
Ligations, anterior tibial, 725 

arterial, principles, 717 

axillary, 722 

brachial, 722 

common carotid, 719 



Ligations, dorsalis pedis, 726 

external carotid, 720 

facial, 720 

femoral, 724 

lingual, 720 

occipital, 720 

posterior tibial, 726 

radial, 723 

subclavian, 720 

superior thyroid, 720 

ulnar, 724 
Lingual artery, ligation, 720 
Link, tracheotomy, 482 
Lipomas, removal, 801 
Lips, wounds, 85 
Little-finger amputation, 735 
Little toe amputations, 762 
Liver, hemorrhage, 541 

injuries, 546 

suture, 547 
Local anesthesia, 18 
Lower extremity, fractures, 251 
Lower jaw, dislocation, 326 
Lowery, compound fracture, 285 
Luckett, Fourth-of-July injuries, 199 
Ludlow, wounds, diaphragm, 121 
Lud wig's angina, 386 
Lung, abscess, 502 

gunshot wounds, 150 

hernia, 113, 118 

rupture, 116 

stab wounds, 116 

suture, 490 

Malaleuca sempervirens, 701 
Malar bone fracture, 308 
Mammary gland abscess, 393 
Marsee, fracture of fingers, 24 

injuries to hand, 102 

suture of tendons, 355 
Martin, Cesarean section, 684 
Mastoiditis, 522 
Mastoid operation, 523 
Materials for sutures, 25 
Maxilla, fractures, 308 












INDEX 



825 



Mayo, umbilical hernia, 630 
Mayor's sling, 293 
Meatus, foreign bodies, 452 
Median nerve exposure, 362 

injury, 361 
Meningeal hemorrhage, 307 
Mesentery, hemorrhage, 540 

repair, 541 
Metacarpals, amputations, 743 

fracture 246 
Metal splints, 50 

McEwen, strangulated hernia, 617 
McFarland, antitetanic powder, 199 
McGrath, appendicitis, 564 
Middle-finger amputation, 733 
Middle meningeal artery, hemor- 
rhage, 307 
Miller, kidney, injury, 553 
Miller, pelvic abscess, 414 
Mitchell, peritonitis, 574 
Morley, bandage for eye, 47 
Morris, appendicitis, 558 
Morrison, wounds of eye, 89 
Mosetig-Moorhof bone wax, 434 
Mothe, dislocation of shoulder, 317 
Motor-oculi nerve injury, 360 
Mouth burns, 472 

Moynihan, intestinal anastomosis, 
650 

purulent peritonitis, 573 
Murphy, anesthesia, 24 
Murphy button, 656 

purulent peritonitis, 574 

suture of arteries, 717 
olecranon, 235 
Musculocutaneous nerve, 371 
Musculo-spiral nerve exposure, 371 

injury, 370 

Xares, plugging, 68 
Nasal bone, fracture, 309 
septum, abscess, 381 
Nassau, esophagotomy, 487 
Xausea, anesthesia, 17 
Neck, bandage, 45 



Neck wounds, 86 

gunshot, 169 
Neff, rupture of urethra, 688 
Nelaton's line, 251 
Nephrectomy, 553 
Nerve, compression, 358 

contusion, 358 

grafting, 359 

suturing, 357 

wounds, 358 
gunshot, 139 
Nerves, individual, 359 

abducens, 359 

anterior crural, 367 

auditory, 359 

circumflex, 366 

facial, 359 

fifth, 360 

genito-crural, 369 

ilio-inguinal, 369 

laryngeal, 360 

median, 361 

motor-oculi, 360 

musculo-cutanecus, 371 

musculo-spiral, 365 

obturator, 368 

optic, 360 

peroneal, 370 

phrenic, 360 

pneumogastric, 360 

popliteal, 370 

radial, 365 

recurrent laryngeal, 360 

sciatic, 369 

tibial anterior, 371 
posterior, 372 

trifacial, 361 

ulnar, 362 
Noetzel, wounds of spleen, 550 
Nose, foreign bodies, 454 

hemorrhage, 68 

Obstruction of bowel, 577 
Obturator artery ligation, 368 
dislocation, 333 



826 



INDEX 



Obturator hernia, strangulated, 628 

nerve, 368 
Occipital artery ligation, 720 
CEdema of the glottis, 483 
CEsophagotomy, 484 
(Esophagus, foreign bodies, 455 

injuries, 87 
Ointment of Reclus, 471 
Olecranon, fracture, 233 
Oliver, strangulated hernia, 617 

jaw fracture, 310 
Omentum, hemorrhage, 539 

resection, 645 

torsion, 674 
Open wounds of thorax, 115 
Operation in private houses, 6 
Operative hemorrhage, 64 

wounds, 75 
Opium, appendicitis, 563 
Optic nerve injury, 360 
Os calcis, Pirogoff 's amputation, 769 

fracture, 281 
Oschner, appendicitis, 564 

femoral hernia, 645 

torsion, 670 
Osteomyelitis, acute, 432 

femur, 438 

humerus, 437 

tibia, 435 
Ovarian cysts, torsion of pedicle, 667 

Pagenstecher, linen, 25 
Palmar abscess, 398 

arches, 66 
Panaris, 422 
Pancreas, gunshot wounds, 153 

injuries, 549 

suture, 549 
Pannett, shell wounds, 174 
Pantzer, appendicitis, 559 
Paracentesis, ear-drum, 523 

pericardium, 498 

pleura, 504 
Paraphimosis, 790 
Parotid gland abscess, 382 



Patella, dislocation, 336 

fracture, 264 

wiring, 266 
Peck, wounds of heart, 497 
Pedicles, ligation, 667 
Pelvic abscess, 411 
Pelvis, fractures, 297 
Penis, injuries, 106 
Perborate of soda, epistaxis, 70 
Peri-anal abscess, 403 
Pericardiotomy, 500 
Pericardium, paracentesis, 498 

puncture, 498 

suture, 490 

wounds, 122 
Perineal abscess, 404 

bruises, 714 

section, 715 
Peritonitis, purulent, 576 

treatment, 577 

typhoid, 576 

septic, 576 
Peroneal nerve, 370 

tendons, dislocation, 347 
PfafT, appendicitis, 562 

tubal pregnancy, 679 
Phalanges, fractures, 247 
Pharynx, foreign bodies, 455 
Phimosis, wounds, 89 
Phlegmon, 421 

arm, 429 

fingers, 424 

forearm, 427 

neck, 429 

perineum, 714 

tendon sheaths, 424 
Phrenic nerve, 360 
Picric acid, burns, 471 
Piles operation, 784 
Pinna, wounds, 84 
PirogofFs amputation, 769 
Plantar abscess, 400 
Plaster-of-Paris bandages, 49 

Bavarian, 51 

preservation, 4 



INDEX 



827 



Piaster-of-Paris splints, 50 
Pleura, empyema, 509 
incision, 509 
puncture, 504 

wounds, 116 
Pneumogastric nerve, 360 
Pneumothorax, 112 
Poisoned wounds, 71 
Popliteal abscess, 398 

artery compression, 67 
Porter, treatment of wounds, 78 
Posterior nares, plugging, 69 

tibial artery, 726 
nerve, 372 
Post-operative ileus, 586 
Potain's aspirator, 504 
Pott's fracture, 276 
Precordial wounds, 122 
Pregnancy, extra-uterine, 674 
Preparation, emergency opera- 
tions, 8 

hands, 9 

skin, 8 
Primary hemorrhage, 57 
Probang, foreign bodies, 458 
Preperitoneal hernia, 614 
Prostatic abscess, 404 
Psoas abscess, 418 
Pulse, abdominal injury, 126 

appendicitis, 559 

chloroform anesthesia, 13 

ether anesthesia, 15 

hemorrhage, 58 

shock, 53 
Puncture, bladder, 707 

knee-joint, 445 

pericardium, 498 

pleura, 504 

scrotum, 796 
Punctured wounds, 76 
Purulent pericarditis, 500 

pleurisy, 502 



Quadriceps extensor tendon, 
ture, 348 



rup- 



Quenu, preparation of room, 8 
Quinsy, 388 

Radial artery, compression, 67 
ligation, 723 

synovial sheath drainage, 424 
Radius, fractures, 237 

gunshot, 160 

head, 236 

lower end, 241 

neck, 236 

shaft, 238 
Ranzi, torsions, 668 
Reclus, lacerated wounds, 100 

ointment, 471 
Rectal injections, 581 
Rectum, abscess, 403 

dilatation, 783 

foreign bodies, 462 

hemorrhoids, 784 

wounds, 108 
Recurrent laryngeal nerve, 360 
Reduction "en masse," 602 

dislocations, 313 

fractures, 204 

hernia, 601 
Removal of small tumors, 804 
Resection of bowel, 651 
Respiratory paralysis, 14, 15 
Responsibility of general practi- 
tioner, 2 
Retention of urine, 698 
Retropharyngeal abscess, 389 
Rev er din, skin grafting, 807 
Reynolds, Cesarean section, 684 
Ribs, fracture, 295 

resection, 504 
Rinchea, torsions, 674 
Ring-finger amputation, 733 
Robinson, shock, 56 
Romer, fracture, clavicle, 292 
Rongeur forceps, 511 
Rossi, fractures, 205 
Rosving, appendicitis, 558 
Royster, fracture of humerus, 220 



828 



INDEX 



Rubber gloves, 10 
Rugine, 506 

Rupture, tubal pregnancy, 675 
urethra, 686 

Saber splint, 184 

Sacro-iliac synchondrosis, 298 

Saline solution in hemorrhage, 55 

sepsis, 574 
Sayres' dressing, 291 
Scalds, 468 
Scalp, abscesses, 379 

arteries, 66 

contusion, 81 

hematoma, 303 

wounds, 81 
Scapula, amputations, 759 

fracture, 294 
Schaute, Cesarean section, 685 
Schleich's formulae, 20 
Sciatic nerve injury, 369 
Sclerotic wounds. 90 
Scrotum, injuries, 106 
Scudder, fracture of leg, 272 
Sebaceous cysts, removal, 804 
Secondary hemorrhage, 57 
Semilunar cartilages, dislocation, 335 
Seminal ducts, abscess, 408 
Senn, first aid on battlefield, 179 

fracture of femur, 254 

hip-joint amputation, 779 

intussusception, 584 
Septic arthritis, 440 
Septum nasi abscess, 381 
Shaving skin, 8 
Shell wounds, 172 
Shock, 52 

diagnosis, 53 

treatment, 54 
Shoulder amputation, 749 

arthrotomy, 448 

bandage, 45 

dislocations, 312 

fractures, 213 
Shrapnel wounds, 172 



Silk sutures, 25 
Silkworm sutures, 26 
Simons, crushing wounds, 99 
Skin grafting, 807 

preparation, 10 
Skull, bullet wounds, 144, 167 

fracture, base, 299 
compound, 303 
vault, 301 

trephining, 510 
Spence, shoulder amputation, 754 
Spermatic cord, ligation, 800 

torsion, 671 

vasectomy, 408 
Spica for breast, 44 

foot, 39 

groin, 41 

shoulder, 45 
Spinal anesthesia, 22 

cord injuries, 297 
Spine, fractures, 296 

gunshot wounds, 148, 170 

wounds, 104 
Spleen, hemorrhage, 549 

injuries, 549 

removal, 550 

rupture, 550 

torsion, 615 
Splenectomy, 550 
Splint, Bavarian, 51 

Dupuytren's, 277 

first aid, 180 

Hodgen's, 262 
Splints, 48 

cradle, 164 

Dutch cane, 48 

Gooch's, 48 

metal, 49 

plaster-of-Paris, 50 

silicate of potash, 48 

trough, 164 

wire gauze, 49 

wooden, 48 
Sprains, 343 
St. Andrew's cross, 44 



INDEX 



829 



Stab wounds, 76 

abdomen, 129 

heart, 425 

knee, 342 

thigh, 95 

thorax, no 
Sterilization, dressing, 7 

hands, 9 

instruments, 8 

skin, 10 
Stimson, pain in fracture, 202 
Stomach, hemorrhage, 152 

hernia, 617 

suture, 546 

wounds, 546 
Stew T art, suture of heart, 496 
Stovaine, spinal anesthesia, 22 
Strangulated hernia, 598 

complications, 612 

diagnosis, 599 

femoral, 617 

inguinal, 603 

obturator, 628 

operation, 603 

taxis, 600 

umbilical, 622 
Stricture of urethra, 694 
Stump bandage, 48 
Subclavian artery, compression, 66 

ligation, 720 
Subclavicular dislocation, 316 
Subcoracoid dislocation, 312 
Subcutaneous wounds, 72 
Subcuticular suture, 30 
Subglenoid dislocation, 322 
Submammary abscess, 395 
Submaxillary abscess, 385 
Subphrenic abscess, 414 
Subpubic dislocation, 332 
Subspinous dislocation, 324 
Suicide, attempts, 186 
Superior maxilla fracture, 308 

thyroid artery ligation, 720 
Suprapubic cystotomy, 695 

puncture, 707 



Surgical dressings, 35 
Suture of arteries, 717 

bladder, 555 

heart, 495 

intestine, 543 

liver, 547 

lung, 490 

nerves, 357 

pancreas, 549 

tendons, 353 

ureter, 556 

wounds, 25 
Sutures, catgut, 26 

continuous, 27 

horsehair, 25 

interrupted, 29 

Lembert, 544 

linen, 25 

methods and materials, 25 

Pagenstecher linen, 26 

quilted, 25 

sero-serous, 543 

silk, 25 

silkworm-gut, 26 

subcuticular, 30 
Syme's amputation, 770 
Syncope, 58 
Synovial sheath suppurations, 424 

cysts, 806 

Tampon for intercostal hemor- 
rhage, 68 

Tapping, hydrocele, 796 

Tarso-metatarsal, amputation, 767 

Tarsus, dislocations, 336 
fracture, 280 

Taxis, indications, 600 

technic femoral hernia, 603 
inguinal hernia, 601 
umbilical, 533, 603 

Taylor, empyema, 502 

fracture of humerus, 221 

Temporal artery compression, 66 

Temporo-maxillary joint disloca- 
tion, 326 



8 3 o 



INDEX 



Tendon, dislocations, 347 

divided, 351 

rupture, 347 

suture, 353 

wounds, 347 
Testis, removal, 798 

suture, 107 

wounds, 107 
Tetanus, bolo wounds, 174 

Fourth-of-July injuries, 199 

prophylaxis, 199 

punctured wounds, 76 
Thiersch, skin grafting, 808 
Thigh, amputations, 777 

wounds, 95 
Thoracotomy, indications, 488 

technic, 488 
Thorax, injuries, no 

open wounds, 116 
Throat, cut, 86 
Thrombosis, lateral sinus, 523 
Thumb, amputations, 738 

bandage, 45 

dislocations, 329 

fracture, 247 
Tibia, fractures, 270 

osteomyelitis, 435 

trephining, 436 
Tibial arteries, ligation, 725 

compression, 67 
Tillaux's dressing, 258 
Toe-nail, ingrowing, 801 
Toes, amputation, 760 
Tongue, abscess, 388 
suture, 85 
wounds, 85 
Tongue-traction, asphyxia, 16 
Tonsil, abscess, 388 
Torsion, arteries, 62 
diagnosis, 667 
omentum, 674 
pedicle ovarian cysts, 667 

spleen, 673 
spermatic cord, 671 
uterus, 669 



Townsend, catheterization, 699 
Toy-pistol wound, 198 
Trachea, foreign bodies, 459 

gunshot wounds, 169 

incised wounds, 88 
Tracheotomy, after-treatment, 479 

foreign bodies, 481 

indications, 477 

operations, 477 

tubes, 477 
Transfixion apparatus, 162 
Travers, suture of the heart, 496 
Trephine, Doyen, 514 

Gait, 514 
Trephining, femur, 438 

fracture of skull, 510 

gunshot wounds, 520 

humerus, 437 

tibia, 435 
Treves, stangulated hernia, 608 
Trunk injuries, no 
Tubal pregnancy, diagnosis, 675 

operation, 677 

rupture, 675 
Tubercular abscess, 378 
Turner, chest wounds, 150 
Tumors, superficial, 804 
Tunica vaginalis, resection, 797 
Turpentine burns, 471 
Tuttle, imperforate anus, 666 
Typhoid perforation, 577 

Ulna, fractures, 237 
Ulnar artery, ligation, 724 

nerve exposure, 362 
injury, 362 

synovial sheath, 424 
Umbilical hernia, strangulated, 
622 

radical cure, 550, 627 
Ureter, repair, 556 

wounds, 556 
Urethra, anatomy, 688 

catheterization, 695 

contusions, 689 



INDEX 



831 



Urethra, foreign bodies, 465 

rupture bulbous portion, 690 

diagnosis, 687 

membranous portion, 696 

pendulous portion, 697 

symptoms, 688 

treatment, 690 
Urethral forceps, 465 
Urethrotomy, 691 
Urgent craniectomy, 510 

thoracotomy, 488 
Urinary abscess, 712 
Urine, extravasation, 712 

retention, 698 
Uterus, torsions, 669 

Vagina, abscess, 410 
injuries, 105 

Vagus nerve, 360 

Valentine, emergency catheteriza- 
tion, 699 

Van der Walker, emergency 
surgery, 6 

Van Hook's anastomosis, 556 

Vasectomy, 408 

Vaughn, wounds of heart, 124 

Vault of skull fracture, 301 
compound, 303 

Veins of liver, ligation, 547 

Velpeau's bandage, 290 

Venous hemorrhage, 57 

Vincent, trephining, 518 

Vineberg, tubal pregnancy, 676 

Vertebrae, fractures, 296 

Viscera, abdominal, rupture, 126 

Volvulus, 579 

Von Bergman, gunshot wounds, 
144 

Vulva, wounds, 105 

Vulvar abscess, 409 

Vulvo-vaginal abscess, 410 
injuries, 105 

Wagner, heart injuries, 124 
Waite, shock, 52 



Walker, fractures of femur, 255 
Warbasse, treatment of fracture, 

205 
Wathen, wounds of liver, 547 
Westmoreland, tracheotomy, 478 
Whitehorne-Cole, gunshot wounds of 

brain, 147 
Whitman, fracture of femur, 255 
Wick drains, 33 
Wire gauze splints, 49 
Wiring fractured fingers, 249 

olecranon, 233 

patella, 266 
Wooden splints, 48 

trough splint, 165 
Wounds, abdomen, 128 

aseptic, 74 

base of thorax, 119 

bend of elbow, 95 

bladder, 554 

blank cartridge, 199 

bolo, 173 

chest, no 

cleansing, 79 

contused, J2 

definitions, 71 

diaphragm, 122 

drainage, 93 

dressings, 78 

elbow, 94 

esophagus, 89 

extremities, 92 

eye, 89 

eyelids, 85 

face, 84 

femoral artery, 95 

fingers, 101 

general principles, 71 

gunshot, civil, 186 
military, 133 

hand, 102 

head, 81 

heart, 122 

hemorrhage, 73 

incised, 73 



8 3 2 



INDEX 



Wounds, infected, 79 
intestine, 543 
kidney, 552 
lacerated, 76 
larynx, 88 
lips, 84 
liver, 546 
lung, 116 
neck, 86 
open, 71 
operative, 75 
pancreas, 549 
penis, 106 
pericardium, 122 
pharynx, 89 
pinna, 84 
pleura, 116 
precordial, 122 
punctured, 76 
rectum, 108 
scalp, 81 
scrotum, 106 
shell, 172 
special regions, 81 
spine, 104 
spleen, 549 



Wounds, stab, 76 

stomach, 546 

subcutaneous, 72 

suture, 26 

symptoms, J2 

testicle, 107 

thigh, 95 

thorax, no 

tongue, 85 

toy pistols, 199 

trachea, 88 

treatment, 70 

trunk, no 

ureter, 556 

vagina, 105 

vulva, 105 

wrist, 92 
Wrist, arthrotomy, 448 

dislocation, 340 

fractures, 246 

wounds, 92 

X-ray, foreign bodies, 457 
fractures, 2 03 

Zone of anesthesia, 19 



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